Author Affiliations:1 Centre for Global Health, University of Dublin, Trinity College, Dublin, 2 University of Malawi, College of Medicine, Centre for Reproductive Health, Malawi, 3 Ifakara Health Institute, Dar Es Salaam, Tanzania, 4 Averting Maternal Death and Disability Program (AMDD), Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, USA

Option 1- Scientific / Empirical Research Findings Presented as – Oral Presentation

Aims:

To explore the perceptions of district health management teams (DHMT) in Tanzania and Malawi on their role as supervisors and the challenges to effective supervision at the district level.

Methods:

This qualitative study took place from Oct-Dec 2008 as part of a broader project, “Health System Strengthening for Equity: The Power and Potential of Mid- Level Providers”. Semi-structured interviews with DHMT personnel in Malawi (n=20) and Tanzania (n=39) covered a range of human resource management (HRM) issues. These included supervision and performance assessment, staff job descriptions and roles, motivation and working conditions.

Results:

Participants reported considerable autonomy in supervision of facilities in their districts but displayed varying attitudes to the nature and purpose of the supervision process. Much of the discourse in Malawi centred on inspection and control; interviewees in Tanzania were more likely to articulate a paradigm represented by support and improvement. In both countries facility level performance metrics dominated. The lack of competency based indicators or clear standards to assess individual health worker performance was considered problematic. Shortages of staff were a major impediment to carrying out regular supervisory visits. Other challenges included conflicting and multiple responsibilities of DHMT staff, and financial constraints.

Discussion/conclusions/ implications:

Supervision is a central component of HRM, not just a quality assurance mechanism. It plays a key role in performance and motivation, and is particularly important in a challenging work environment or in the context of task shifting. Policy level attention is crucial to ensure a systematic, structured process that is based on common understandings of the role and purpose of supervision. It needs to be adequately resourced and supported in order to improve health worker performance and retention at the district level.

Author Affiliations:University of Malawi, Dept. of Epidemiology & Public Health Medicine, Royal College ofSurgeons in Ireland

Option 1- Scientific / Empirical Research Findings Presented as – Oral Poster

Aims:

The study is being conducted to assess the impact of task shifting on the quality and coverage of HIV and primary health care services in Malawi.

Methods:

Trend data was collected for immunisation, PHC, HIV and AIDS and health workers for the period 2006-2010 from seven health facilities in two districts in Malawi. One-on-one in-depth interviews were also held with health service managers at the district and facility levels to discuss the trends and to get their views on task shifting.

Results:

With the exception of Health Surveillance Assistants (HSAs) whose numbers doubled, nurse and clinician numbers remained fairly stable. HTC services more than trebled between 2006 and 2009 but there have been either declines or level for immunisation and family planning (FP) services. Findings from interviews with district and facility staff suggest that the declining HIV and immunisation trends are due to stock-outs of drugs.

There are mixed views on the use of HSAs to scale up HIV services in addition to surveillance and provision of other PHC services in the communities. Proponents are arguing that task shifting is reducing workload for nurses and clinicians while at the same time bringing services to the remote areas. Opponents doubt quality of care and biased time allocation against non-office community surveillance work amid low supervision and absence of incentives for the HSAs to do more community-based work.

Discussion/conclusions/ implications:

Task shifting has increased HIV service coverage but this may be leading to declining PHC services as HSAs take-on more facility based HIV work. There is therefore need to strengthen the training and mentorship of the HSAs to ensure service quality and for HSAs to balance time allocation against competing demands so as to improve the image of their contribution to health service delivery. Causes of drug stock-outs should be properly analysed and addressed.

Authors:Blum LS., Sultana M., Bilkis S., Nahar Q., Akhtar R., Streatfield PK.


Author Affiliations:International Centre for Diarrheal Disease Research, Bangladesh (ICDDR,B)

Option 1- Scientific / Empirical Research Findings Presented as – Poster (unable to present)

Aims:

A nationwide survey shows an impressive reduction in maternal mortality in Bangladesh, declining from 322 to 194 in 9 years, with hemorrhage and eclampsia the leading causes of death. Little is known about the circumstances that prevent or encourage women with complications to use emergency obstetric care.

Methods:

Qualitative research was carried out alongside with the national survey between March 2010 and January 2011. Maternal deaths were sampled from the survey, near-misses were identified from health facilities located in areas where the deaths occurred. Methods included in-depth interviews with people most familiar with maternal death (15) or near-miss (16) that had occurred due to hemorrhage and eclampsia within past 18 months.

Results:

Informants from both groups demonstrated limited knowledge of delivery-related complications and where to seek treatment. Maternal deaths were more likely to obtain initial treatment with informal providers, delaying care seeking to facilities, while near-miss women generally first sought facility care. Additional household level delays to care seeking faced by women who died included older family members’ opposition to facility care, odd night time, and money was not readily available. Once care was sought, maternal deaths were more likely to go to a facility that was unable to provide appropriate treatment, either because of the unavailability of doctors or required services, forcing women to visit multiple facilities before obtaining appropriate care. Data showed that eclampsia was easier to recognize, signaling the need for formal care, while hemorrhage was difficult to identify, with the majority of deaths never accessing facility services.

Conclusions:

Prior to childbirth, women and family members should be informed about pregnancy-related complications and where to seek appropriate care. Health officials must ensure that EmOC services are functioning and rapid referral systems are in place.

Author Affiliations: 1Royal College of Surgeons in Ireland, 2London School of Hygiene and Tropical Medicine

Option 1- Scientific / Empirical Research Findings

Presented as - Poster

Aims:

This study aimed to analyse researchers’ experiences of health research collaborations involving academic institutions in lower and higher income countries, using Zambia as a case study. This phase of the study takes the perspectives of Zambian researchers.

Methods:

A mapping of international health research collaborations was followed by in-depth interviews in March 2011 of 20 Zambian researchers, with sampling reflecting different types of partnerships, research experience, disciplines, and a gender balance.

Results:

• 
  Most Zambian researchers reported that research priority setting was done by northern research donors and researchers, and did not always coincide with Zambian priorities. However, proposal development was generally collaborative.


• 
  All interviewees reported inequities in funding mechanisms, which channelled funds exclusively through northern institutions.


• 
  Most collaborations received ethical approval in both Zambia and partner countries. Many interviewees reported that northern researchers’ lacked understanding of research ethical issues at local level, for example around informed consent.


• 
  Where northern researchers participated in data collection, they often visited Zambia for only short periods of time. Consequently, they had insufficient time to immerse themselves in the socio-cultural context of Zambia.


• 
  Participants reported that analysis was undertaken jointly between northern and Zambian researchers, although some reported the only role Zambians performed was one of data collector.


• 
  Zambian researchers report that that health research capacity in Zambia is lagging behind their northern partners. Many Zambian researchers undertake consultancies, which detract from producing research outputs.

Discussion/conclusions/ implications:

North-south power differences continue to dominate health research collaborations involving Zambia and the global north. To address this imbalance, Zambian researcher capacity must be augmented, not just to undertake research, but to manage and coordinate such collaborations. Additionally, northern researchers need a better understanding of Zambian research culture and context.

Author Affiliations: 1Department of Paediatrics, University of Khartoum, Sudan, 2University College Cork, Ireland, 3Alneelain University, Sudan, 4Faculty of Nursing Science, University of Khartoum, Sudan. 5Sunnybrook Hospital, New York, 6Darfur, Sudan, 7University of Alabama at Birmingham, US

Option 1- Scientific / Empirical Research Findings

Presented as - Poster

Background:

Every year an estimated four million newborns die during their first month of life, 50% dying during delivery and the first 24 hours of life. HBB is a low-cost, neonatal resuscitation curriculum developed for resource-limited circumstances. HBB emphasizes skilled attendance at birth, assessment of every baby, temperature support, stimulation to breathe, and assisted ventilation if necessary, within “The First Golden Minute” after birth.

Aims:

The aim of this paper is to propose an ICRCT of HBB into rural Sudan, focusing on training 14,000 VMs, distributed over 18 Regions/provinces and covering a rural population of 25 million.

Methodology:

An ICRCT is a trial in which groups of subjects (in this case, villages) are randomized. Advantages of ICRCT over individually RCT include the ability to study interventions while preventing "contamination" across individuals. Approximately 200 Clusters with 200-300 annual deliveries per cluster will be sufficient to obtain statistical power.

Implementation:

Following cluster randomization, Regional Instructors (RIs) will be trained by HBB Master Trainers. RIs will then train HBB to the VMs in the villages randomized to the intervention group. Accurate outcome data collection will be essential to the project. Thus, VMs in both the control and treatment groups will be trained on how to accurately collect perinatal outcome data. The control villages would be "controls in waiting" in that they would receive HBB training once the outcome of the trial was confirmed as positive.

The Outcomes:

Stillbirth rates and neonatal death in the first 7 days will be the primary outcomes. Many babies currently classified as stillborn in national statistics, will often survive with effective resuscitation. In situations where neonatal follow up is questionable, neonatal mortality within 24 hours of birth will be analyzed.

Conclusion:

ICRCTs are a powerful and feasible way to address important educational initiatives in resource poor countries.

Author Affiliations:1Dept of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, RCSI, 2Centre for Global Health, Trinity College Dublin, 3ChRAIC is a partnership of: College of Medicine, Malawi; Makerere University School of Public health (MUSPH), Uganda; Malaria Consortium, South Sudan and Uganda; Medical Research Centre (MRC), Sierra Leone; Ministry of Health, Republic of South Sudan; National University of Ireland, Galway (NUIG), Ireland; National University of Lesotho; Royal College of Surgeons in Ireland (RCSI); Trinity College Dublin (TCD), Centre for Global Health, Ireland; University of Medical Sciences and Technology, Khartoum, Sudan. Additional support to the partnership is provided by two organizations based at the World Health Organization in Geneva, the Alliance for Health Policy and Systems Research (AHPSR) and the Council on Health Research for Development (COHRED)

Option 1- Scientific / Empirical Research Findings

Presented as - Oral Presentation

Aims:

This paper examines the processes whereby health systems researchers, members of the Connecting health Research in Africa and Ireland Consortium (ChRAIC), worked with national policy makers and knowledge users in seven African countries

Methods:

(i) proceedings from a ChRAIC partner workshop in Kampala in April 2009 in which country policy-makers participated; (ii) a half day ChRAIC partner workshop in November 2010 to analyse the involvement of policy makers; and (iii) telephone interviews with the ChRAIC country team investigators (8 interviews)

Results:

Policy makers and researchers agreed that research was more likely to be relevant to their contexts and research outputs more likely to be used if policy makers were involved in the research process.

Different approaches to researcher-policy maker collaborations were adopted in different countries, which depended on the broader political and environmental contexts and pre-existing personal relationships. Challenges to achieving sustained and productive involvement of policy makers in research processes included:

• 
  Given the uncertain time-frames and high turnover of policy-makers there is the need to go beyond the individual contacts and relationships – depersonalising the relationship;


• 
  Recognition that developing and maintaining the partnership is a time-consuming process;


• 
  Alignment and harmonisation of research processes with the activities and cycles of policy makers causes delays, which can impinge on research donor expectations

Discussion/conclusions/ implications:

No single approach or blueprint suited these different national contexts. However four themes emerged:

• 
  Developing a strong institutional link and track record with the relevant government departments is necessary for trust to be established;


• 
  Expectations and motivations of the team members (researchers and policy makers alike) needs to be negotiated and reviewed periodically;


• 
  Clarity is needed on the activities, roles and responsibilities for each team member, and;


• 
  Recognition by all parties, including research funders, that building partnerships is a time-consuming process, which may delay outputs

A unique and strategic collaborative partnership among research and advocacy organizations - Health System Strengthening for Equity (HSSE) explicitly and strategically sought to strengthen obstetric care delivery by building an evidence base on the contribution of mid-level providers (MLP) and promoting greater political leadership and critical policy action on this issue. National and global level advocacy activities included supporting/developing local advocacy groups and using the high profile of key partners to raise awareness and debate on MLPs and task shifting at roundtable meetings and ministerial conferences.

Key challenges the partnership encountered such as ownership and management of data, decision making, leveraging partner opportunities for the project, and aligning research and advocacy outputs are highlighted. The project has contributed to building the capacity of southern and northern institutions to use evidence for policy and to link global and national processes ensuring all stakeholders are working together to generate more realistic and sustainable approaches to strengthening health systems.