Assessing sustainment of health worker outcomes beyond program end: Evaluation results from an infant and young child feeding intervention in Bangladesh.

Introduction: Alive and Thrive (A&T) implemented infant and young child feeding (IYCF) interventions in Bangladesh. We examine the sustained impacts on health workers' IYCF knowledge, service delivery, job satisfaction, and job readiness three years after the program's conclusion.

Methods: We use data from a cluster-randomized controlled trial design, including repeated cross-sectional surveys with health workers in 2010 (baseline,  = 290), 2014 (endline,  = 511) and 2017 (post-endline,  = 600).

Examining decentralization and managerial decision making for child immunization program performance in India.

Despite widespread adoption of decentralization reforms, the impact of decentralization on health system attributes, such as access to health services, responsiveness to population health needs, and effectiveness in affecting health outcomes, remains unclear. This study examines how decision space, institutional capacities, and accountability mechanisms of the Intensified Mission Indradhanush (IMI) in India relate to measurable performance of the immunization program. Data on decision space and its related dimensions of institutional capacity and accountability were collected by conducting structured interviews with managers based in 24 districts, 61 blocks, and 279 subcenters.

Decentralization Can Improve Equity, but Can It Be Sustained?

A major theoretical issue about health system reform involving decentralization has been whether it promotes equity of health system funding. An article by the principal author and others in 2003 showed that, under certain conditions and policies, decentralization improved the equity of allocation of financial resources to different income levels of municipalities in Colombia and Chile. Another recurring issue has been whether reforms can be sustained over time.

What is the impact of removing performance-based financial incentives on community health worker motivation? A qualitative study from an infant and young child feeding program in Bangladesh.

Background: Community health worker (CHW) motivation is an important factor related to health service quality and CHW program sustainability in low- and middle-income countries. Financial and non-financial motivators may influence CHW behavior through two dimensions of motivation: desire to perform and effort expended. The aim of this study was to explore how the removal of performance-based financial incentives impacted CHW motivation after formal funding ceased for Alive and Thrive (A&T), an infant and young child feeding (IYCF) program in Bangladesh.

Can complex programs be sustained? A mixed methods sustainability evaluation of a national infant and young child feeding program in Bangladesh and Vietnam.

Background: Poor early-life nutrition is a major barrier to good health and cognitive development, and is a global health priority. Alive & Thrive (A&T) was a multi-pronged initiative to improve infant and young child feeding behaviors. It aimed to achieve at-scale child health and nutrition improvements via a comprehensive approach that included nutrition counseling by health workers, policy change, social mobilization and mass media activities.

Health Reform in the Midst of a Social and Political Crisis in Chile, 2019-2020.

The protests in Chile in October 2019 raised the issue of health reform to the public agenda again. This article reviews some of the explanations for why there was a widespread protest, including the expectations of continued progress, the emergence of a "fear-based populism" and the decline in legitimacy of most social and political actors. Using the theories of Kingdon to explain how reforms are placed on the political agenda, we describe how the protests raised health reform as a problem to be addressed, discuss the tendency toward consensus on policy options by technical health reform advocates, and examine the uncertain political processes that would be necessary for a consensus reform to be adopted and implemented.

Performance of volunteer community health workers in implementing home-fortification interventions in Bangladesh: A qualitative investigation.

Introduction: BRAC, an international development organisation based in Bangladesh, uses female volunteer community health workers called Shasthya Shebika (SS), who receive small incentives to implement its home-fortification interventions at the community level. This paper examines the individual, community and BRAC work environment factors that exert an influence on the performance of SS.

Methods: This qualitative study was conducted between the period of June 2014 to December 2016 as part of a larger evaluation of BRAC's home-fortification programme.

Role of home visits by volunteer community health workers: to improve the coverage of micronutrient powders in rural Bangladesh.

Objective: We assessed the role of home visits by Shasthya Shebika (SS) - female volunteer community health workers (CHWs) - in improving the distribution of micronutrient powder (MNP), and explored the independent effects of caregiver-provider interaction on coverage variables.

Design: We used data from three cross-sectional surveys undertaken at baseline (n 1927), midline (n 1924) and endline (n 1540) as part of an evaluation of a home fortification programme. We defined an exposure group as one that had at least one SS visit to the caregiver's household in the 12 months preceding the survey considering three outcome variables - message (ever heard), contact (ever used) and effective coverage (regular used) of MNP.

Developing a conceptual framework for implementation science to evaluate a nutrition intervention scaled-up in a real-world setting.

Objective: The aim of this paper is to identify and develop a comprehensive conceptual framework using implementation science that can be applied to assess a nutrition intervention in a real-world setting.

Design: We conducted a narrative review using electronic databases and a manual search to identify implementation science frameworks, models and theories published in peer-reviewed journals. We performed a qualitative thematic analysis of these publications to generate a framework that could be applied to nutrition implementation science.

Factors associated with home visits by volunteer community health workers to implement a home-fortification intervention in Bangladesh: a multilevel analysis.

Objective: BRAC, an international development organization based in Bangladesh, engages community health workers called Shasthya Shebikas (SS) to implement home fortification of foods with micronutrient powders (MNP). We identified factors associated with home visits by SS, at different levels of the BRAC programme-delivery hierarchy, to implement home-fortification interventions.

Design: We conducted a cross-sectional survey, semi-structured interviews, and collected programme-related data from sub-districts included in the caregiver survey of BRAC's home-fortification programme and performed multilevel logistic regression modelling to investigate factors associated with home visits by SS.

A synthesis of implementation science frameworks and application to global health gaps.

Background: Implementation science has been growing as discipline in the past decades, producing an increasing number of models in the area. On the other hand, most frameworks are intended to guide the implementation of programs, focusing on identifying elements and stages that increase their success. This article aims to structure this discussion, proposing a simplified tool that synthesizes common elements of other frameworks, and highlight the usefulness to use implementation science not only in identifying successful implementation strategies but as a tool to assess gaps in global health initiatives.

The impact of monetary incentives on referrals by traditional birth attendants for postnatal care in Nigeria.

Background: Gaps in postnatal care use represent missed opportunities to prevent maternal and neonatal death in sub-Saharan Africa. As one in every three non-facility deliveries in Nigeria is assisted by a traditional birth attendant (TBA), and the TBA's advice is often adhered to by their clients, engaging TBAs in advocacy among their clients may increase maternal and neonatal postnatal care use. This study estimates the impact of monetary incentives for maternal referrals by TBAs on early maternal and neonatal postnatal care use (within 48 h of delivery) in Nigeria.

Health service delivery and political trust in Nigeria.

Do improvements in health service delivery affect trust in political leaders in Africa? Citizens expect their government to provide social services. Intuitively, improvements in service delivery should lead to higher levels of trust in and support for political leaders. However, in contexts where inadequate services are the norm, and where political support is linked to ethnic or religious affiliation, there may be weak linkages between improvements in service delivery and changes in trust in political leaders.

Improving the performance of community health workers in Swaziland: findings from a qualitative study.

Background: The performance of community health workers (CHWs) in Swaziland has not yet been studied despite the existence of a large national CHW program in the country. This qualitative formative research study aimed to inform the design of future interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusing on four CHW programs, we aimed to determine what potential changes to their program CHWs and CHW program managers perceive as likely leading to improved performance of the CHW cadre.

Harmonization of community health worker programs for HIV: A four-country qualitative study in Southern Africa.

Background: Community health worker (CHW) programs are believed to be poorly coordinated, poorly integrated into national health systems, and lacking long-term support. Duplication of services, fragmentation, and resource limitations may have impeded the potential impact of CHWs for achieving HIV goals. This study assesses mediators of a more harmonized approach to implementing large-scale CHW programs for HIV in the context of complex health systems and multiple donors.

Harmonizing community-based health worker programs for HIV: a narrative review and analytic framework.

Background: Many countries have created community-based health worker (CHW) programs for HIV. In most of these countries, several national and non-governmental initiatives have been implemented raising questions of how well these different approaches address the health problems and use health resources in a compatible way. While these questions have led to a general policy initiative to promote harmonization across programs, there is a need for countries to develop a more coherent and organized approach to CHW programs and to generate evidence about the most efficient and effective strategies to ensure their optimal, sustained performance.

Household coverage of Swaziland's national community health worker programme: a cross-sectional population-based study.

Objectives: To ascertain household coverage achieved by Swaziland's national community health worker (CHW) programme and differences in household coverage across clients' sociodemographic characteristics.

Methods: Household survey from June to September 2015 in two of Swaziland's four administrative regions using two-stage cluster random sampling. Interviewers administered a questionnaire to all household members in 1542 households across 85 census enumeration areas.

Distrusting community health workers with confidential health information: a convergent mixed-methods study in Swaziland.

Background: Patients are unlikely to share the personal information that is critical for effective healthcare, if they do not trust that this information will remain confidential. Trust in confidentiality may be particularly low in interactions with community health workers (CHW) because CHW deliver healthcare outside the clinic setting. This study aims to determine the proportion of Swaziland's population that does not trust the national CHW cadre with confidential medical information, and to identify reasons for distrust.

Sustainability of health information systems: a three-country qualitative study in southern Africa.

Background: Health information systems are central to strong health systems. They assist with patient and program management, quality improvement, disease surveillance, and strategic use of information. Many donors have worked to improve health information systems, particularly by supporting the introduction of electronic health information systems (EHIS), which are considered more responsive and more efficient than older, paper-based systems.

Decision Space and Capacities in the Decentralization of Health Services in FijiComment on "Decentralisation of Health Services in Fiji: A Decision Space Analysis".

The study of decentralization in Fiji shows that increasing capacities is not necessarily related to increasing decision space of local officials, which is in contrast with earlier studies in Pakistan. Future studies should address the relationship among decision space, capacities, and health system performance.

PEPFAR Investments In Governance And Health Systems Were One-Fifth Of Countries' Budgeted Funds, 2004-14.

Launched in 2003, the US President's Emergency Plan for AIDS Relief (PEPFAR) is the largest disease-focused assistance program in the world. We analyzed PEPFAR budgets for governance and systems for the period 2004-14 to ascertain whether PEPFAR's stated emphasis on strengthening health systems has been manifested financially. The main outcome variable in our analysis, the first of its kind using these data, was the share of PEPFAR's total annual budget for a country that was designated for governance and systems.

Improving Health System Performance in a Decentralized Health System: Capacity Building in Pakistan.

-Key policy questions on decentralization in health relate to whether and in which ways health sector decentralization can improve health outcomes. Focusing on a maternal, neonatal, and child health program in Pakistan, this study examines relationships between three dimensions of decentralization: the degree of local decision-making choice ("decision space"), individual and institutional capacities, and local accountability. Additionally, these relationships are examined at two points in time to assess whether "capacity building" interventions, as well as any changes in decision space, are related to improvements in health sector performance as measured by improved administrative processes and indicators of health coverage in important primary care services.

Global Fund investments in human resources for health: innovation and missed opportunities for health systems strengthening.

Background: Since the early 2000s, there have been large increases in donor financing of human resources for health (HRH), yet few studies have examined their effects on health systems.

Objective: To determine the scope and impact of investments in HRH by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the largest investor in HRH outside national governments.

Methods: We used mixed research methodology to analyse budget allocations and expenditures for HRH, including training, for 138 countries receiving money from the Global Fund during funding rounds 1-7.