BACKGROUND: Routine health information systems (RHISs) are an essential source of data to inform decisions and actions around health facility performance, but RHIS data use is often limited in low and middle-income country contexts. Determinants that influence RHIS data-informed decisions and actions are not well understood, and few studies have explored the relationship between RHIS data-informed decisions and actions.
METHODS: This qualitative thematic analysis study explored the determinants and characteristics of successful RHIS data-informed actions at the health facility level in Mozambique and which determinants were influenced by the Integrated District Evidence to Action (IDEAs) strategy. Two rounds of qualitative data were collected in 2019 and 2020 through 27 in-depth interviews and 7 focus group discussions with provincial, district and health facility-level managers and frontline health workers who participated in the IDEAs enhanced audit and feedback strategy. The Performance of Routine Information System Management-Act framework guided the development of the data collection tools and thematic analysis.
RESULTS: Key behavioural determinants of translating RHIS data into action included health worker understanding and awareness of health facility performance indicators coupled with health worker sense of ownership and responsibility to improve health facility performance. Supervision, on-the-job support and availability of financial and human resources were highlighted as essential organisational determinants in the development and implementation of action plans. The forum to regularly meet as a group to review, discuss and monitor health facility performance was emphasised as a critical determinant by study participants.
CONCLUSIONS: Future data-to-action interventions and research should consider contextually feasible ways to support health facility and district managers to hold regular meetings to review, discuss and monitor health facility performance as a way to promote translation of RHIS data to action.

Routine assessment of health facility capacity to provide abortion and post-abortion care can inform policy and programmes to expand access and improve quality. Since 2018, abortion and/or post-abortion care have been integrated into two WHO health facility assessment tools: the Service Availability and Readiness Assessment and the Harmonised Health Facility Assessment. We discuss lessons learnt through experiences integrating abortion into these standardised tools. Our experiences highlight the feasibility of including abortion in health facility assessments across a range of legal contexts. Factors facilitating the integration of abortion include cross-country collaboration and experience sharing, timely inputs into tool adaptations, clear leadership, close relationships among key stakeholders as in assessment coordination groups, use of locally appropriate terminology to refer to abortion and reference to national policies and guidelines. To facilitate high-quality data collection, we identify considerations around question sequencing in tool design, appropriate terminology and the need to balance the normalisation of abortion with adequate sensitisation and education of data collectors. To facilitate appropriate and consistent analysis, future work must ensure adequate disaggregation of recommended and non-recommended abortion methods, alignment with national guidelines and development of a standardised approach for measuring abortion service readiness. Measurement of abortion service availability and readiness should be a routine practice and a standardised component of health facility assessment tools. Evidence generated by health facility assessments that include abortion monitoring can guide efforts to expand access to timely and effective care and help normalise abortion as a core component of sexual and reproductive healthcare.

BACKGROUND: Indigenous communities worldwide lead calls for all evaluations of research, programmes and policies affecting their communities to reflect the values, priorities and perspectives of the Indigenous peoples and communities involved. Tools, such as the Quality Appraisal Tool (QAT), are available to assess research quality through an Indigenous cultural lens. Good evaluation requires that evaluation efforts be evaluated. We found that critical reflection on the quality of evaluations from an Indigenous perspective is largely absent from the published literature. To ensure that we strive for quality in evaluation as determined by Indigenous people with whom we work, we examined the quality of our own evaluation of an Indigenous health research collaboration by conducting a reflexive dialogue.
METHODS: The QAT was used to assess our evaluation according to Indigenous health research principles. Our qualitative study used analytical coautoethnography to generate data through a series of reflexive dialogue sessions with Indigenous and non-Indigenous members of the research collaboration, using the QAT criteria as discussion prompts. Our ideas and reflections were compared and contrasted through a collaborative and iterative writing process, multiple review cycles and discussions.
RESULTS: We documented our findings against the QAT framework. We found examples that each QAT principle had, to some extent, been adhered to, but constantly needed to assess whether the principles were fully achieved to our satisfaction. Strengths of the evaluation included being adaptable and responsive to emerging issues for the research collaboration, while areas for improvement included more Indigenous leadership of, and involvement in, evaluation.
CONCLUSIONS: Although reflexive evaluation practice is not always comfortable, it does provide an opportunity to generate insights for improvement. Reflecting as we did-in a partnership between Indigenous and non-Indigenous colleagues-enabled deeper insights and meaning. We anticipate that our process models how other research in Indigenous contexts might better advance ethical, quality Indigenous research through working in collaboration with Indigenous researchers and communities.

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The Proactive Community Case Management (ProCCM) trial in Mali reinforced the health system across both arms with user fee removal, professional community health workers (CHWs) and upgraded primary health centres (PHCs)-and randomized village-clusters to receive proactive home visits by CHWs (intervention) or fixed site-based services by passive CHWs (control). Across both arms, sick children\'s 24-hour treatment and pregnant women\'s four or more antenatal visits doubled, and under-5 mortality halved, over 3 years compared with baseline. In the intervention arm, proactive CHW home visits had modest effects on children\'s curative and women\'s antenatal care utilization, but no effect on under-5 mortality, compared with the control arm. We aimed to explain these results by examining implementation, mechanisms and context in both arms We conducted a process evaluation with a mixed method convergent design that included 79 in-depth interviews with providers and participants over two time-points, surveys with 195 providers and secondary analyses of clinical data. We embedded realist approaches in novel ways to test, refine and consolidate theories about how ProCCM worked, generating three context-intervention-actor-mechanism-outcome nodes that unfolded in a cascade. First, removing user fees and deploying professional CHWs in every cluster enabled participants to seek health sector care promptly and created a context of facilitated access. Second, health systems support to all CHWs and PHCs enabled equitable, respectful, quality healthcare, which motivated increased, rapid utilization. Third, proactive CHW home visits facilitated CHWs and participants to deliver and seek care, and build relationships, trust and expectations, but these mechanisms were also activated in both arms. Addressing multiple structural barriers to care, user fee removal, professional CHWs and upgraded clinics interacted with providers\' and patients\' agency to achieve rapid care and child survival in both arms. Proactive home visits expedited or compounded mechanisms that were activated and changed the context across arms.

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BACKGROUND: Co-creation is seen as a way to ensure all relevant needs and perspectives are included and to increase its potential for beneficial effects and uptake process evaluation is crucial. However, existing process evaluation frameworks have been built on practices characterised by top-down developed and implemented interventions and may be limited in capturing essential elements of co-creation. This study aims to provide a review of studies planning and/or conducting a process evaluation of public health interventions adopting a co-creation approach and aims to derive assessed process evaluation components, used frameworks and insights into formative and/or participatory evaluation.
METHODS: We searched for studies on Scopus and the Health CASCADE Co-Creation Database. Co-authors performed a concept-mapping exercise to create a set of overarching dimensions for clustering the identified process evaluation components.
RESULTS: 54 studies were included. Conceptualisation of process evaluation included in studies concerned intervention implementation, outcome evaluation, mechanisms of impact, context and the co-creation process. 22 studies (40%) referenced ten existing process evaluation or evaluation frameworks and most referenced were the frameworks developed by Moore et al (14%), Saunders et al (5%), Steckler and Linnan (5%) and Nielsen and Randall (5%).38 process evaluation components were identified, with a focus on participation (48%), context (40%), the experience of co-creators (29%), impact (29%), satisfaction (25%) and fidelity (24%).13 studies (24%) conducted formative evaluation, 37 (68%) conducted summative evaluation and 2 studies (3%) conducted participatory evaluation.
CONCLUSIONS: The broad spectrum of process evaluation components addressed in co-creation studies, covering both the evaluation of the co-creation process and the intervention implementation, highlights the need for a process evaluation tailored to co-creation studies. This work provides an overview of process evaluation components, clustered in dimensions and reflections which researchers and practitioners can use to plan a process evaluation of a co-creation process and intervention.

The International Health Regulations Monitoring and Evaluation Framework (IHRMEF) includes four components regularly conducted by States Parties to measure the current status of International Health Regulations (IHR) 2005 core capacities and provide recommendations for strengthening these capacities. However, the four components are conducted independently of one another and have no systematic referral to each other before, during or after each process, despite being largely conducted by the same team, country and support organisations. This analysis sets out to identify ways in which IHRMEF components could work more synergistically to effectively measure the status of IHR core capacities, taking into account the country\'s priority risks. We developed a methodology to allow these independent components to communicate with each other, including expert consultation, a qualitative crosswalk analysis and a country-level quantitative analysis. The demonstrated results act as a proof of concept and illustrate a methodology to provide benefits across all four components before, during and after implementation.

Currently, about 8% of deaths worldwide are maternal or neonatal deaths, or stillbirths. Maternal and neonatal mortality have been a focus of the Millenium Development Goals and the Sustainable Development Goals, and mortality levels have improved since the 1990s. We aim to answer two questions: What were the key drivers of maternal and neonatal mortality reductions seen in seven positive-outlier countries from 2000 to the present? How generalisable are the findings?We identified positive-outlier countries with respect to maternal and neonatal mortality reduction since 2000. We selected seven, and synthesised experience to assess the contribution of the health sector to the mortality reduction, including the roles of access, uptake and quality of services, and of health system strengthening. We explored the wider context by examining the contribution of fertility declines, and the roles of socioeconomic and human development, particularly as they affected service use, the health system and fertility. We analysed government levers, namely policies and programmes implemented, investments in data and evidence, and political commitment and financing, and we examined international inputs. We contextualised these within a mortality transition framework.We found that strategies evolved over time as the contacts women and neonates had with health services increased. The seven countries tended to align with global recommendations but could be distinguished in that they moved progressively towards implementing their goals and in scaling-up services, rather than merely adopting policies. Strategies differed by phase in the transition framework-one size did not fit all.

BACKGROUND: Maternal mortality in Nepal dropped from 553 to 186 per 100 000 live births during 2000-2017 (66% decline). Neonatal mortality dropped from 40 to 21 per 1000 live births during 2000-2018 (48% decline). Stillbirths dropped from 28 to 18 per 1000 births during 2000-2019 (34% decline). Nepal outperformed other countries in these mortality improvements when adjusted for economic growth, making Nepal a \'success\'. Our study describes mechanisms which contributed to these achievements.
METHODS: A mixed-method case study was used to identify drivers of mortality decline. Methods used included a literature review, key-informant interviews, focus-group discussions, secondary analysis of datasets, and validation workshops.
RESULTS: Despite geographical challenges and periods of political instability, Nepal massively increased the percentage of women delivering in health facilities with skilled birth attendance between 2000 and 2019. Although challenges remain, there was also evidence in improved quality and equity-of-access to antenatal care and childbirth services. The study found policymaking and implementation processes were adaptive, evidence-informed, made use of data and research, and involved participants inside and outside government. There was a consistent focus on reducing inequalities.
CONCLUSIONS: Policies and programmes Nepal implemented between 2000 and 2020 to improve maternal and newborn health outcomes were not unique. In this paper, we argue that Nepal was able to move rapidly from stage 2 to stage 3 in the mortality transition framework not because of what they did, but how they did it. Despite its achievements, Nepal still faces many challenges in ensuring equal access to quality-care for all women and newborns.