There is limited understanding of why routine immunization (RI) coverage improves in some settings in Africa and not in others. Using a grounded theory approach, we conducted in-depth case studies to understand pathways to coverage improvement by comparing immunization programme experience in 12 districts in three countries (Ethiopia, Cameroon and Ghana). Drawing on positive deviance or assets model techniques we compared the experience of districts where diphtheria–tetanus–pertussis (DTP3)/pentavalent3 (Penta3) coverage improved with districts where DTP3/Penta3 coverage remained unchanged (or steady) over the same period, focusing on basic readiness to deliver immunization services and drivers of coverage improvement. The results informed a model for immunization coverage improvement that emphasizes the dynamics of immunization systems at district level. In all districts, whether improving or steady, we found that a set of basic RI system resources were in place from 2006 to 2010 and did not observe major differences in infrastructure. We found that the differences in coverage trends were due to factors other than basic RI system capacity or service readiness. We identified six common drivers of RI coverage performance improvement—four direct drivers and two enabling drivers—that were present in well-performing districts and weaker or absent in steady coverage districts, and map the pathways from driver to improved supply, demand and coverage. Findings emphasize the critical role of implementation strategies and the need for locally skilled managers that are capable of tailoring strategies to specific settings and community needs. The case studies are unique in their focus on the positive drivers of change and the identification of pathways to coverage improvement, an approach that should be considered in future studies and routine assessments of district-level immunization system performance.

Capacity improvement has become central to strategies used to develop health systems in low-income countries. Experience suggests that achieving better health outcomes requires both increased investment (i.e. financial resources) and adequate local capacity to use resources effectively. International donors and non-governmental agencies, as well as ministries of health, are therefore increasingly relying on capacity building to enhance overall performance in the health sector. Despite the growing interest in capacity improvement, there has been little consensus among practitioners and academics on definitions of 'capacity building' and how to evaluate it. This paper aims to review current knowledge and experiences from ongoing efforts to monitor and evaluate capacity building interventions in the health sector in developing countries. It draws on a wide range of sources to develop (1) a definition of capacity building and (2) a conceptual framework for mapping capacity and measuring the effects of capacity building interventions. Mapping is the initial step in the design of capacity building interventions and provides a framework for monitoring and evaluating their effectiveness. Capacity mapping is useful to planners because it makes explicit the assumptions underlying the relationship between capacity and health system performance and provides a framework for testing those assumptions.

box ► Design is being used more frequently in global health practice but is not reported on sufficiently for transparency, evaluability and wider dissemination. ► Reporting guidelines are useful in improving the quality and quantity of dissemination of work in peer-reviewed literature for global health. ► Building on available literature and current practice in design for global health, we present a reporting guideline that can be used by scholars and practitioners applying design in their work, and invite input on this work. ► We present draft guidance which we recommend for reporting on design for global health in order to improve the evidence base for design in global health.

This article considers the challenges of generalizability related to case studies, and specifically for the in-depth case studies of the Africa Routine Immunization System Essentials (ARISE) project. The article describes how these challenges were addressed, by developing a Theory of Change to frame case selection strategies, data collection, and analysis, including synthesis of findings across multiple cases. The authors then consider: the importance of grounding generalizability in theory; balancing within-and cross-case analyses for synthesis; and using theory-based case selection, as ways to support generalizability of the case study findings. Multiple case studies should sequence analysis as: 1) within-case analysis; 2) identification of replicated findings and implementation variation across cases; and 3) synthesis across cases, pooling the data. Case selection should be a stand-alone, formative part of case study research. The lessons from the ARISE case studies suggest that these are important ways in which case study methodology can be strengthened.

Implementing partners, designers, and funders need tools and common language to increase the understanding and application of human-centered design (HCD) as an approach that enhances global health programming.n To advance the integration of HCD and global health, designers and implementing partners should be able to articulate how HCD and global health practice can work together to support the achievement of health sector and global health ecosystem goals.