BackgroundWeak health information systems (HIS) are a critical challenge to reaching the health-related Millennium Development Goals because health systems performance cannot be adequately assessed or monitored where HIS data are incomplete, inaccurate, or untimely. The Population Health Implementation and Training (PHIT) Partnerships were established in five sub-Saharan African countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) to catalyze advances in strengthening district health systems. Interventions were tailored to the setting in which activities were planned.Comparisons across strategiesAll five PHIT Partnerships share a common feature in their goal of enhancing HIS and linking data with improved decision-making, specific strategies varied. Mozambique, Ghana, and Tanzania all focus on improving the quality and use of the existing Ministry of Health HIS, while the Zambia and Rwanda partnerships have introduced new information and communication technology systems or tools. All partnerships have adopted a flexible, iterative approach in designing and refining the development of new tools and approaches for HIS enhancement (such as routine data quality audits and automated troubleshooting), as well as improving decision making through timely feedback on health system performance (such as through summary data dashboards or routine data review meetings). The most striking differences between partnership approaches can be found in the level of emphasis of data collection (patient versus health facility), and consequently the level of decision making enhancement (community, facility, district, or provincial leadership).DiscussionDesign differences across PHIT Partnerships reflect differing theories of change, particularly regarding what information is needed, who will use the information to affect change, and how this change is expected to manifest. The iterative process of data use to monitor and assess the health system has been heavily communication dependent, with challenges due to poor feedback loops. Implementation to date has highlighted the importance of engaging frontline staff and managers in improving data collection and its use for informing system improvement. Through rigorous process and impact evaluation, the experience of the PHIT teams hope to contribute to the evidence base in the areas of HIS strengthening, linking HIS with decision making, and its impact on measures of health system outputs and impact.

BackgroundDespite advances in medical technology and public health practice at the global level over the past millennia, infectious diseases are still the leading causes of death in most resource limited countries. Stronger infectious disease surveillance and response systems in developed countries facilitated the near elimination of infectious disease related deaths in those countries. Today, low-income countries are following this path by strengthening disease surveillance and response strategies that would help reverse the trend in infectious disease associated morbidity and mortality cases. In 2000, Zambia adopted the World Health Organisation Regional Office for Africa’s (WHO-AFRO) Integrated Disease Surveillance and Response Strategy (IDSR) to monitor, prevent and control priority notifiable infectious diseases in the country. Through this strategy, activities pertaining to disease surveillance are coordinated and streamlined to take advantage of similar surveillance functions, skills, resources and targeted populations. The purpose of the study was to investigate and report on the existing challenges in the implementation of the IDSR strategy in a resource limited country from a health worker perspective.MethodsA qualitative study approach was used to achieve the study aim. Data was collected through key informant interviews with selected persons at the Lusaka Province Health Office (LPHO); Lusaka and Chongwe District Health Management Team Offices; and four selected health facilities in the two districts (two from each). Thematic analysis approach was used to analyse the qualitative data.ResultsThe major successes included operationalised response and epidemic preparedness at all levels (National to district); full-time staff and budget dedicated to disease surveillance at all levels and adoption of the 2010 World Health Organisations’ Integrated Disease Surveillance and Response Strategy technical guidelines to the Zambian context. Several challenges hampered effective implementation. These include inadequate trained human resources, poor infrastructure and coordination challenges.ConclusionThe implementation of IDSR strategy in Zambia has recorded some successes. However, several gaps hinder effective implementation. It is imperative that these gaps are addressed for Zambia to have a robust surveillance system that could inform policy in a comprehensive and timely manner.

IntroductionHealth worker motivation can potentially affect the provision of health services. Low morale among the workforce can undermine the quality of service provision and drive workers away from the profession. While the presence of high-quality, motivated staff is a key aspect of health system performance, it is also one of the most difficult factors to measure.MethodsWe assessed health worker motivation as part of the baseline assessment for a health system strengthening intervention in three rural districts in Zambia. The intervention (Better Health Outcomes Through Mentoring and Assessment (BHOMA)) aims to increase health worker motivation through training, mentoring and support. We assessed motivation by examining underlying issues grouped around relevant outcome constructs such as job satisfaction, general motivation, burnout, organization commitment, conscientiousness and timeliness that collectively measure overall levels of motivation. The tools and the concepts have been used in high-income countries and they were recently applied in African settings to measure health worker motivation.ResultsFemale participants had the highest motivation scores (female: mean 78.5 (SD 7.8) vs male: mean (SD 7.0)). By type of worker, nurses had the highest scores while environmental health technicians had the lowest score (77.4 (SD 7.8 vs 73.2 (SD 9.3)). Health workers who had been in post longer also had higher scores (>7 months). Health workers who had received some form of training in the preceding 12 months were more likely to have a higher score; this was also true for those older than 40 years when compared to those less than 40 years of age. The highest score values were noted in conscientiousness and timeliness, with all districts scoring above 80.ConclusionsThis study evaluated motivation among rural health workers using a simple adapted tool to measure the concept of motivation. Results showed variation in motivation score by sex, type of health worker, training and time in post. Further research is needed to establish why these health worker attributes were associated with motivation and whether health system interventions targeting health workers, such as the current intervention, could influence health worker motivation.

IntroductionWhile in school, girls require an environment that is supportive of menstrual hygiene management (MHM) in order to ensure regular school attendance and participation. Little is known about schoolgirls access to and practice of MHM in rural Zambia. This study explores girls’ experiences of MHM in rural schools of Zambia from the perspectives of schoolgirls, schoolboys and community and school-based adults key to MHM for schoolgirls.MethodsIn July and August 2015, we conducted this qualitative exploratory study in six rural schools of Mumbwa and Rufunsa districts of Zambia. Twelve in-depth interviews (IDIs) and six focus group discussions (FGDs) were conducted among girls ages 14–18 who had begun menstruating. Two FGDs with boys ages 14–18 and 25 key informant interviews were also conducted with teachers, female guardians and traditional leaders to provide the context within which schoolgirls practice MHM.ResultsMost girls reported learning about menstruation only at menarche and did not know the physiological basis of menstruation. They reported MHM-related challenges, including: use of non-absorbent and uncomfortable menstrual cloth and inadequate provision of sanitary materials, water, hygiene and sanitation facilities (WASH) in schools. In particular, toilets did not have soap and water or doors and locks for privacy and had a bad odor. Girls’ school attendance and participation in physical activities was compromised when menstruating due to fear of teasing (especially by boys) and embarrassment from menstrual leakage. Boys said they could tell when girls were menstruating by the smell and their behaviour, for instance, moving less and isolating themselves from their peers. Girls complained of friction burns on their inner thighs during their long journey to school due to chaffing of wet non-absorbent material used to make menstrual cloth. Girls preferred to dispose used menstrual materials in pit latrines and not waste bins for fear that they could be retrieved for witchcraft against them. Though traditional leaders and female guardians played a pivotal role in teaching girls MHM, they have not resolved challenges to MHM among schoolgirls.ConclusionWhen menstruating, schoolgirls in rural Zambia would rather stay home than be uncomfortable, inactive and embarrassed due to inadequate MHM facilities at school. A friendly and supportive MHM environment that provides education, absorbent sanitary materials and adequate WASH facilities is essential to providing equal opportunity for all girls.Electronic supplementary materialThe online version of this article (10.1186/s12889-018-6360-2) contains supplementary material, which is available to authorized users.

Microbicides are most usually conceptualised within a disease prevention framework and studies usually define acceptability in terms of product characteristics, willingness to use and risk reduction. This starting point has led to assumptions about microbicides which, rather than being challenged by empirical studies, have tended to foreclose the data and subsequent conceptual models. Few studies take an emic ('insider') perspective or attempt to understand how microbicides fit into the broader context of women's and men's everyday lives. As part of the integrated social science component of the MDP301 Phase III microbicide trial, in-depth interviews were conducted with female trial participants in South Africa, Zambia, Tanzania and Uganda. Women's experiences of the gel challenge several assumptions that have commonly been reiterated about microbicides. Our analysis suggests that current definitions and conceptual frameworks do not adequately account for the range of meanings that women attribute to gel. Even within the context of a clinical trial, it is possible to obtain a richer, ethnographic and cross-cultural concept of acceptability based on women's practice and emic interpretations. We now need to move beyond limited notions of acceptability and consider how microbicides fit into a more holistic picture of women's and men's sexuality and sexual health.

BackgroundResearch has shown that the modes of leadership and management may influence health outcomes. However, majority of health leaders and managers in many low-income countries are promoted on account of clinical expertise. It has been recognised that these new managers are often ill-prepared for managing complex health systems. In response to this challenge, the Zambian Ministry of Health (MoH) has developed the Governance and Management Capacity Building (GMCB) Strategic Plan (2012–2016), whose overarching goal is to improve health sector governance and create an environment that is result-oriented, accountable and transparent. This led to the introduction of a new in-service leadership and management course, which has come to be known as the Zambia Management and Leadership Academy (ZMLA). This paper presents the results of an impact evaluation of the ZMLA programme conducted in 2014.MethodsThis was a cross-sectional mixed method study. The study targeted health workers, stakeholders and course implementers. ZMLA trainees were targeted to gain perspectives on the extent to which the programme affected levels of self-confidence resulting from knowledge gained. Perspectives were sought from both ZMLA and non ZMLA trainees to measure changes in the work environment. Stakeholder perspectives were collected from trainers and key informants involved in providing ZMLA training.ResultsOn average, knowledge levels increased by 38% after each workshop. A comparison of the average self-rated scores from 444 management and leadership survey responses before ZMLA and after ZMLA training showed a significant increase in the proportion of participants that felt adequately trained to undertake management and leadership, from 63% (before) to 99% (after) in phase 1 and 43% (before) to 98% (after) in the phase II cohort. The calculated before and after percentage change for work environment themes ranged from 5.8% to 13.4%. Majority of respondents perceived improvements in the workplace environment, especially in handling human resource management matters. The smallest improvement was noted in ethics and accountability. Qualitative interviews showed improvements in the meeting culture and a greater appreciation for the importance of meetings. Shared vision, teamwork and coordination seemed to have improved more in work places where the overall manager had received ZMLA training.ConclusionLeadership and management training will be a key ingredient in health system strengthening in low-income settings. The ZMLA model was found to be acceptable and effective in improving knowledge and skills for health system managers with minimal disruption to health services.

The objective of this study is to describe HIV-testing among men in rural Lusaka Province, Zambia, using a population-based survey for a cluster-randomized trial. Households (N = 120) were randomly selected from each of the 42 clusters, defined as a health facility catchment area. Individuals aged 15-60 years were invited to complete questionnaires regarding demographics and HIV-testing history. Men testing in the last year were defined as recent-testers. After questionnaire completion adults were offered home-based rapid HIV-testing. Of the 2,828 men, 53 % reported ever-testing and 25 % recently-testing. Factors independently associated with ever- and recent-testing included age 20+ years, secondary/higher education, being married or widowed, a history of TB-treatment and higher socioeconomic position. 53 % of never-testers and 57 % of men who did not report a recent-test accepted home-based HIV-testing. Current HIV-testing approaches are inadequate in this high prevalence setting. Alternative strategies, including self-testing, mobile- or workplace-testing, may be required to complement facility-based services.

IntroductionSub-Saharan Africa is experiencing an epidemiological transition as the burden of NCDs overtake communicable diseases. However, it is unknown what capacity and gaps exist at primary care level to address the growing burden of NCDs. This study aimed to assess the Zambian health system’s capacity to address in NCDs, using an adapted WHO Essential Non Communicable Disease Interventions (WHO PEN) tool.MethodologyThis was a cross-sectional facility survey in the three districts conducted from September 2017 to October 2017. We defined facility readiness along five domains: basic equipment, essential services, diagnostic capacity, counseling services, and essential medicines. For each domain, we calculated an index as the mean score of items expressed as percentage. These indices were compared to an agreed cutoff at 70%, meaning that a facility index or district index below 70% off was considered as ‘not ready’ to manage NCDs at that level. All analysis were performed using Stata 15 MP.ResultsThere appeared to be wide heterogeneity between facilities in respect of readiness to manage NCDs. Only 6 (including the three 1st level hospitals) out of the 46 facilities were deemed ready to manage NCDs. Only the first level hospitals scored a mean index higher than the 70% cut off; With regard to medications needed to manage NCDs, urban and rural health facilities were comparably equipped. However, there was evidence that calcium channel blockers (p = 0.013) and insulin (p = 0.022) were more likely to be available in urban and semi-urban health facilities compared to rural facilities.ConclusionOur study revealed gaps in primary health care capacity to manage NCDs in Zambia, with almost all health facilities failing to reach the minimum threshold. These results could be generalized to other similar districts in Zambia and the sub-region, where health systems remain focused on infectious rather than non-communicable Disease. These results should attract policy attention and potentially form the basis to review current approach to NCD care at the primary care level in Zambia and Sub-Saharan Africa.