From PERFORM to PERFORM2Scale: lessons from scaling-up a health management strengthening intervention to support Universal Health Coverage in three African countries.

Strengthening management and leadership competencies among district and local health managers has emerged as a common approach for health systems strengthening and to achieve Universal Health Coverage (UHC). While the literature is rich with localized examples of initiatives that aim to strengthen the capacity of district or local health managers, particularly in sub-Saharan Africa, considerably less attention is paid to the science of 'how' to scale-up these initiatives. The aim of this paper is thus to examine the 'process' of scaling-up a management strengthening intervention (MSI) and identify new knowledge and key lessons learned that can be used to inform the scale-up process of other complex health interventions, in support of UHC.

The role of healthcare providers in expanding legal abortion: Qualitative insights from Argentina, Ireland, and South Korea.

Abortion laws are key in creating an enabling environment that facilitates the advancement of people's sexual and reproductive health and rights. Around 50 countries have liberalized their abortion laws in the last decades by adding new grounds allowing abortion. The road toward the expansion of legal abortion is a long, highly sensitive, and difficult process.

Teamwork in community health committees: a case study in two urban informal settlements.

Background: Community health committees (CHCs) are mechanisms for community participation in decision-making and overseeing health services in several low-and middle-income countries (LMICs). There is little research that examines teamwork and internal team relationships between members of these committees in LMICs. We aimed to assess teamwork and factors that affected teamwork of CHCs in an urban slum setting in Nairobi, Kenya.

Community bylaws concerning sexual and reproductive health and rights in Machinga District, Malawi: to what extent are they responsive to young people's needs?

Background: Community bylaws are commonly accepted mechanisms to influence behaviour change to achieve better health and development outcomes in sub-Saharan Africa. However, the uses, benefits, and potential downsides of community bylaws are largely unclear, especially regarding sexual and reproductive health and rights (SRHR) of young people. The objective of this study was to determine the extent to which community bylaws in Machinga District in southern Malawi are responsive to young people's realities and SRHR needs.

"You are a child and this is not your business": Decision-making on child marriage in Sindh, Pakistan.

Young people in Pakistan face challenges such as child marriage, which have adverse consequences on their education, employment, health and overall well-being. We conducted interviews (26) and focus group discussions (12) with young people (15 to 24 years) and community stakeholders to understand how child marriage is perceived by them and to gain insight into the decision-making regarding marriage of youth in Sindh, Pakistan. Study findings show that many young people wish to marry later, but recognize that child marriage is used as a protective strategy to cope with poverty and prevent sexual activity prior to marriage.

Drivers of child marriage in specific settings of Ethiopia, Indonesia, Kenya, Malawi, Mozambique and Zambia - findings from the Yes I Do! baseline study.

Background: Child marriage persists in many countries and has severe impacts on health, education, economic and social status of girls. Child marriage has many interlinked causes. This study aimed to explore the drivers of child marriage in specific contexts in Ethiopia, Indonesia, Kenya, Malawi, Mozambique and Zambia.

Community participation in the health system: analyzing the implementation of community health committee policies in Kenya.

Background: Community health committees (CHCs) are a mechanism for communities to voluntarily participate in making decisions and providing oversight of the delivery of community health services. For CHCs to succeed, governments need to implement policies that promote community participation. Our research aimed to analyze factors influencing the implementation of CHC-related policies in Kenya.

How context influences the functionality of community-level health governance structures: A case study of community health committees in Kenya.

Community Health Committees (CHCs) are mechanisms through which communities participate in the governance and oversight of community health services. While there is renewed interest in strengthening community participation in the governance of community health services, there is limited evidence on how context influences community-level structures of governance and oversight. The objective of this study was to examine how contextual factors influence the functionality of CHCs in Kajiado, Migori, and Nairobi Counties in Kenya.

How to scale-up: a comparative case study of scaling up a district health management strengthening intervention in Ghana, Malawi and Uganda.

Background: The need to scale up public health interventions in low- and middle-income countries to ensure equitable and sustainable impact is widely acknowledged. However, there has been little understanding of how projects have sought to address the importance of scale-up in the design and implementation of their initiatives. This paper aims to gain insight into the facilitators of the scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda.

Human Resources for Health in Conflict Affected Settings: A Scoping Review of Primary Peer Reviewed Publications 2016-2022.

Background: Conflict has devastating effects on health systems, especially on healthcare workers (HCWs) working in under-resourced and hostile environments. However, little evidence is available on how policy-makers, often together with development partners, can optimize the organization of the health workforce and support HCWs to deliver accessible and trustworthy health services in conflict-affected settings (CAS).

Methods: A scoping review was conducted to review recent evidence (2016-2022) on human resources for health (HRH) in CAS, and critically discuss HRH challenges in these settings.

Young people's choice and voice concerning sex and relationships: effects of the multicomponent Get Up Speak Out! Programme in Iganga, Uganda.

Background: Young people in Uganda face challenges in achieving their sexual and reproductive health and rights (SRHR), such as lack of information, limited access to services, teenage pregnancy and sexually transmitted infections. To address this, their empowerment - including their ability to express themselves and make decisions, is a key strategy. This study assessed how young people's voice and choice concerning sex and relationships changed over the period of 3 years of implementation of the Get Up Speak Out! programme.

Using a theory of change in monitoring, evaluating and steering scale-up of a district-level health management strengthening intervention in Ghana, Malawi, and Uganda - lessons from the PERFORM2Scale consortium.

Background: Since 2017, PERFORM2Scale, a research consortium with partners from seven countries in Africa and Europe, has steered the implementation and scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda. This article presents PERFORM2Scale's theory of change (ToC) and reflections upon and adaptations of the ToC over time. The article aims to contribute to understanding the benefits and challenges of using a ToC-based approach for monitoring and evaluating the scale-up of health system strengthening interventions, because there is limited documentation of this in the literature.

Assessing the scalability of a health management-strengthening intervention at the district level: a qualitative study in Ghana, Malawi and Uganda.

Background: The scale-up of successfully tested public health interventions is critical to achieving universal health coverage. To ensure optimal use of resources, assessment of the scalability of an intervention is recognized as a crucial step in the scale-up process. This study assessed the scalability of a tested health management-strengthening intervention (MSI) at the district level in Ghana, Malawi and Uganda.

Participation in primary health care through community-level health committees in Sub-Saharan Africa: a qualitative synthesis.

Background: Health committees are key mechanisms for enabling participation of community members in decision-making on matters related to their health. This paper aims to establish an in-depth understanding of how community members participate in primary health care through health committees in sub-Saharan Africa (SSA).

Methods: We searched peer-reviewed English articles published between 2010 and 2019 in MEDLINE, Popline and CINAHL databases.

An exploratory study of the barriers and facilitators to the implementation of community health worker programmes in conflict-affected South Sudan.

Background: Community health workers (CHWs) are crucial for increasing access to health services to communities. Due to decades of conflict and under-funding, access to health care in South Sudan remains severely limited. To improve equitable access to healthcare, the government has introduced "the Boma Health Initiative (BHI)", a strategy to harmonise community health programmes across the country.

Community health workers at the dawn of a new era: 9. CHWs' relationships with the health system and communities.

Background: This is the ninth paper in our series, "Community Health Workers at the Dawn of a New Era". Community health workers (CHWs) are in an intermediary position between the health system and the community. While this position provides CHWs with a good platform to improve community health, a major challenge in large-scale CHW programmes is the need for CHWs to establish and maintain beneficial relationships with both sets of actors, who may have different expectations and needs.

Community health workers at the dawn of a new era: 10. Programme performance and its assessment.

Background: While the evidence supporting the effectiveness of community health worker (CHW) programmes is substantial, there is also considerable evidence that many of these programmes have notable weaknesses that need to be addressed in order for them to reach their full potential. Thus, considerations about CHW programme performance and its assessment must be taken into account as the importance of these programmes is becoming more widely appreciated. In this paper, the tenth in our 11-paper series, "Community health workers at the dawn of a new era", we address CHW programme performance and how it is assessed from a systems perspective.

Community health workers at the dawn of a new era: 11. CHWs leading the way to "Health for All".

Background: This is the concluding paper of our 11-paper supplement, "Community health workers at the dawn of a new era".

Methods: We relied on our collective experience, an extensive body of literature about community health workers (CHWs), and the other papers in this supplement to identify the most pressing challenges facing CHW programmes and approaches for strengthening CHW programmes.

Results: CHWs are increasingly being recognized as a critical resource for achieving national and global health goals.

Community health workers at the dawn of a new era: 1. Introduction: tensions confronting large-scale CHW programmes.

Background: Community health worker (CHW) programmes are again receiving more attention in global health, as reflected in important recent WHO guidance. However, there is a risk that current CHW programme efforts may result in disappointing performance if those promoting and delivering them fail to learn from past efforts. This is the first of a series of 11 articles for a supplement entitled "Community Health Workers at the Dawn of a New Era".

Reducing unmet need for contraceptive services among youth in Homabay and Narok counties, Kenya: the role of community health volunteers - a qualitative study.

Background: Access to contraceptive services is a cornerstone of human well-being. While Community Health Volunteers (CHVs) promote family planning in Kenya, the unmet need for contraceptives among youth remains high. CHVs seem to pay little specific attention to the contraceptive needs of the youth.

Being dragged into adulthood? Young people's agency concerning sex, relationships and marriage in Malawi, Mozambique and Zambia.

This study aimed to explore how young people exercise agency in rural Malawi, Mozambique and Zambia in relation to sex, relationships and marriage, to inform local programmes aiming to prevent teenage pregnancy and child marriage. In each country, focus group discussions with young people and parents, in-depth interviews with young people and a variety of other participants, and a household survey with young people (15-24 years) were conducted. We found that (child) marriage was often a response to teenage pregnancy, which was highly prevalent in all study areas.

Measuring motivation among close-to-community health workers: developing the CTC Provider Motivational Indicator Scale across six countries.

Background: Close-to-community (CTC) health service providers are a cost-effective and important resource in the promotion of and increasing access to health services. However, many CTC provider programmes suffer from high rates of de-motivation and attrition due to inadequate support systems. Recent literature has identified the lack of rigorous approaches towards measuring and monitoring motivation among CTC providers as an important gap.