Introduction Despite the growing global application of mobile health (mHealth) technology in maternal and child health, the contextual factors and mechanisms by which interventional outcomes are generated have not been subjected to extensive review. In this study, we sought to identify context, mechanisms and outcome elements from implementation and evaluation studies of mHealth interventions to formulate theories or models explicating how mHealth interventions work (or not) both for health care providers and for pregnant women and new mothers. Method An electronic search of six online databases (Medline, Pubmed, Google Scholar, Scopus, Academic Search Premier and Health Systems Evidence) was performed. Using appropriate MeSH terms and selection procedure, 32 articles were considered for analysis. A theory-driven approach, narrative synthesis, was applied to synthesise the data. Thematic content analysis was used to delineate the elements of the intervention, including its context, actors, mechanism and outcomes. Retroduction was applied to link these elements using a realist evaluation heuristic to form generative theories. Results Mechanisms that promote the implementation of mHealth by community health workers/health care providers include motivation, perceived skill and knowledge improvement, improved self-e cacy, improved con dence, improved relationship between community health workers and clients, perceived support of community health workers, perceived ease of use and usefulness of mHealth, For pregnant women and new mothers, mechanisms that trigger the uptake of mHealth and use of maternal and child health services included: perceived service satisfaction, perceived knowledge acquisition, support and con dence, improved self-e cacy, encouragement, empowerment and motivation. Information overload was identi ed as a potential negative mechanism for the uptake of maternal and child health services. Conclusion The models developed in this study provide a detailed understanding of the implementation and uptake of mHealth interventions and how they improve maternal and child health services in low and middle income countries. These models provide a foundation for the 'white box' or theory-driven evaluation of mHealth intervention and can improve the rollout and implementation where required.

BackgroundRealist evaluation offers an interesting approach to evaluation of interventions in complex settings, but has been little applied in health care. We report on a realist case study of a well performing hospital in Ghana and show how such a realist evaluation design can help to overcome the limited external validity of a traditional case study.MethodsWe developed a realist evaluation framework for hypothesis formulation, data collection, data analysis and synthesis of the findings. Focusing on the role of human resource management in hospital performance, we formulated our hypothesis around the high commitment management concept. Mixed methods were used in data collection, including individual and group interviews, observations and document reviews.ResultsWe found that the human resource management approach (the actual intervention) included induction of new staff, training and personal development, good communication and information sharing, and decentralised decision-making. We identified 3 additional practices: ensuring optimal physical working conditions, access to top managers and managers' involvement on the work floor. Teamwork, recognition and trust emerged as key elements of the organisational climate. Interviewees reported high levels of organisational commitment. The analysis unearthed perceived organisational support and reciprocity as underlying mechanisms that link the management practices with commitment.Methodologically, we found that realist evaluation can be fruitfully used to develop detailed case studies that analyse how management interventions work and in which conditions. Analysing the links between intervention, mechanism and outcome increases the explaining power, while identification of essential context elements improves the usefulness of the findings for decision-makers in other settings (external validity). We also identified a number of practical difficulties and priorities for further methodological development.ConclusionThis case suggests that a well-balanced HRM bundle can stimulate organisational commitment of health workers. Such practices can be implemented even with narrow decision spaces. Realist evaluation provides an appropriate approach to increase the usefulness of case studies to managers and policymakers.

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Bruno Marchal and colleagues argue that most current strategies aimed at health systems strengthening remain selectively targeted at specific diseases.

BackgroundDespite the mounting attention for health systems and health systems theories, there is a persisting lack of consensus on their conceptualisation and strengthening. This paper contributes to structuring the debate, presenting landmarks in the development of health systems thinking against the backdrop of the policy context and its dominant actors. We argue that frameworks on health systems are products of their time, emerging from specific discourses. They are purposive, not neutrally descriptive, and are shaped by the agendas of their authors.DiscussionThe evolution of thinking over time does not reflect a progressive accumulation of insights. Instead, theories and frameworks seem to develop in reaction to one another, partly in line with prevailing paradigms and partly as a response to the very different needs of their developers. The reform perspective considering health systems as projects to be engineered is fundamentally different from the organic view that considers a health system as a mirror of society. The co-existence of health systems and disease-focused approaches indicates that different frameworks are complementary but not synthetic.The contestation of theories and methods for health systems relates almost exclusively to low income countries. At the global level, health system strengthening is largely narrowed down to its instrumental dimension, whereby well-targeted and specific interventions are supposed to strengthen health services and systems or, more selectively, specific core functions essential to programmes. This is in contrast to a broader conceptualization of health systems as social institutions.SummaryHealth systems theories and frameworks frame health, health systems and policies in particular political and public health paradigms. While there is a clear trend to try to understand the complexity of and dynamic relationships between elements of health systems, there is also a demand to provide frameworks that distinguish between health system interventions, and that allow mapping with a view of analysing their returns. The choice for a particular health system model to guide discussions and work should fit the purpose. The understanding of the underlying rationale of a chosen model facilitates an open dialogue about purpose and strategy.

Frameworks can clarify concepts and improve understanding of underlying mechanisms in the domain of health systems research and strengthening. Many existing frameworks have a limited capacity to analyze interactions and equilibriums within a health system overlooking values as an underlying steering mechanism. This paper introduces the health system dynamics framework and demonstrates its application as a tool for analysis and modelling. The added value of this framework is: 1) consideration of different levels of a health system and tracing how interventions or events at one level influence other elements and other levels; 2) emphasizes the importance of values; 3) a central axis linking governance, human resources, service delivery and population, and 4) taking into account the key elements of complexity in analysis and strategy development. We urge  the analysis of individual health systems and meta-analysis, for a better understanding of their functioning and strengthening.

SUMMARYThe health workforce is of strategic importance to the performance of national health systems as well as of international disease control initiatives. The brain drain from rural to urban areas, and from developing to industrialized countries is a long-standing phenomenon in the health professions but has in recent years taken extreme proportions, particularly in Africa. Adopting the wider perspective of health workforce balances, this paper presents an analysis of the underlying mechanisms of health professional migration and possible strategies to reduce its negative impact on health services.The opening up of international borders for goods and labour, a key strategy in the current liberal global economy, is accompanied by a linguistic shift from 'human capital flight' and 'brain drain' to 'professional mobility' or 'brain circulation'. In reality, this mobility is very asymmetrical, to the detriment of less developed countries, which lose not only much-needed human resources, but also considerable investments in education and fiscal income.It is argued that low professional satisfaction and the decreasing social valuation of the health professionals are important determinants of the decreasing attraction of the health professions, which underlies both the push from the exporting countries, as well as the pull from the recipient countries. Solutions should therefore be based on this wider perspective, interrelating health workforce imbalances between, but also within developing and developed countries.