BackgroundCutaneous Leishmaniasis (CL) is a parasitic skin disease, linked to poverty, and belonging to the group of Neglected Tropical Diseases. Depending on the severity, the type of lesions or scars, and the context, CL can lead to self- and social stigma influencing the quality of life and psychological well-being of the patient. This dimension is, however, little documented for the most common, localized form of cutaneous leishmaniasis (LCL).We aimed to describe the current knowledge on the psychological burden and the stigma related to LCL.MethodsThe population of interest for this scoping review are patients or their relatives with localized LCL or related scars.We searched the electronic databases PubMed, Web of Knowledge, PsycINFO, POPLINE, Cochrane Library, Science Direct, Global Health, and LILACS, for articles written in Arabic, English, French, Dutch, Portuguese, or Spanish, and published until the end of August 2017.ResultsFrom 2485 initial records, 15 papers met our inclusion criteria. Dermatology life quality index was the most frequent used scale to assess LCL psychological impact in quantitative studies. Six qualitative studies used individual interviews and/or focus groups discussions to explore the psychological and/or the social burden of this disease. Quantitative assessments using standard scales as well as qualitative research asserts that LCL is a source of psychological suffering, stigmatization, and decreased quality of life (QoL).ConclusionMost studies showed that LCL has a significant negative effect on the QoL and mental health. However, the fact that the psychosocial burden generated by LCL is time-dependent makes it hard to measure. We recommend to develop a more specific and validated assessment scale to appreciate the full burden of this disease and enhance comparability of findings.Electronic supplementary materialThe online version of this article (10.1186/s12889-018-5260-9) contains supplementary material, which is available to authorized users.

Background: Nowadays, health systems are generally acknowledged to be complex social systems. Consequently, scholars, academics, practitioners, and policy-makers are exploring how to adopt a complexity perspective in health policy and system research. While leadership and complexity has been studied extensively outside health, the implications of complexity theories for the study of leadership in healthcare have received limited attention. We carried out a scoping review of complex leadership (CL) in healthcare to investigate how CL in healthcare has been defined, theorised and conceptualised and to explore how ‘CL’ has been applied in healthcare settings. Methods: We followed the methodological steps proposed by (Arksey and O’Malley, 2005): (1) specifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating and summarizing the findings, and (6) reporting the results. We searched using Medline, Psychinfo, Wiley online library, and Google Scholar. Our inclusion criteria were: publication type (peer reviewed articles, theses, and book chapters); phenomenon of interest: complex leadership; context: healthcare and period of publication: between 2000 and 2016. Results: Our search and selection resulted in 37 papers (16 conceptual papers, 14 empirical studies and 7 advocacy papers). We note that empirical studies on CL are few and almost all research reported by these papers was carried out in the North (mainly in USA and UK). We found that there is some variation in definitions of CL. Furthermore, the research papers adopt mostly an explorative or explanatory approach and do not focus on assessing effectiveness of CL approaches. Finally, we found that the majority of researchers seem to adhere to the mathematical complexity perspective. Conclusion: Complexity concepts derived from natural sciences may not automatically fit management of health services. Further research into how social complexity theories may offer researchers useful grounds to empirically test CL theories in health settings is warranted. Specific attention should be paid to the multi-layered nature of leadership.

Background Breast cancer patients in sub-Saharan Africa experience long time intervals between their first presentation to a health care facility and the start of cancer treatment. The role of the health system in the increasing treatment time intervals has not been widely investigated. This review aimed to identify existing information on health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa to contribute to the reorientation of health policies in the region. Methods PubMed, ScienceDirect, African Journals Online, Mendeley, ResearchGate and Google Scholar were searched to identify relevant studies published between 2010 and July 2020. We performed a qualitative synthesis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Related health system factors were extracted and classified according to the World Health Organization’s six health system building blocks. The quality of qualitative and quantitative studies was assessed by using the Critical Appraisal Skills Program Quality-Assessment Tool and the National Institute of Health Quality Assessment Tool, respectively. In addition, we used the Confidence in the Evidence from Reviews of Qualitative Research tool to assess the evidence for each qualitative finding. Results From 14,184 identified studies, this systematic review included 28 articles. We identified a total of 36 barriers and 8 facilitators that may influence diagnostic and treatment intervals in women with breast cancer. The principal health system factors identified were mainly related to human resources and service delivery, particularly difficulty accessing health care, diagnostic errors, poor management, and treatment cost. Conclusion The present review shows that diagnostic and treatment intervals among women with breast cancer in sub-Saharan Africa are influenced by many related health system factors. Policy makers in sub-Saharan Africa need to tackle the financial accessibility to breast cancer treatment by adequate universal health coverage policies and reinforce the clinical competencies for health workers to ensure timely diagnosis and appropriate care for women with breast cancer in this region.

ObjectivesWe aimed at exploring the underlying mechanisms and contextual conditions by which leadership may influence ‘public service motivation’ of health providers in Moroccan hospitals.DesignWe used the realist evaluation (RE) approach in the following steps: eliciting the initial programme theory, designing the study, carrying out the data collection, doing the data analysis and synthesis. In practice, we adopted a multiple embedded case study design.SettingsWe used purposive sampling to select hospitals representing extreme cases displaying contrasting leadership practices and organisational performance scores using data from the Ministry of Health quality assurance programmes from 2011 to 2016.ParticipantsWe carried out, on average, 17 individual in-depth interviews in 4 hospitals as well as 7 focus group discussions and 8 group discussions with different cadres (administrators, nurses and doctors). We collected relevant documents (eg, performance audit, human resource availability) and carried out observations.ResultsComparing the Intervention-Context-Actor-Mechanism-Outcome configurations across the hospitals allowed us to confirm and refine our following programme theory: “Complex leaders, applying an appropriate mix of transactional, transformational and distributed leadership styles that fit organisational and individuals characteristics [I] can increase public service motivation, organisational commitment and extra role behaviours [O] by increasing perceived supervisor support and perceived organizational support and satisfying staff basic psychological needs [M], if the organisational culture is conducive and in the absence of perceived organisational politics [C]”.ConclusionsIn hospitals, the archetype of complex professional bureaucracies, leaders need to be able to balance between different leadership styles according to the staff’s profile, the nature of tasks and the organisational culture if they want to enhance public service motivation, intrinsic motivation and organisational commitment.

ObjectivesThis study aimed at opening the black box of the relationship between leadership and motivation of health workers by focusing on a high-performance hospital in Morocco.DesignWe adopted the realist evaluation approach and used the case study design to test the initial programme theory we formulated on the basis of a scoping review on complex leadership. We used the Intervention-Context-Actors-Mechanism-Outcome Configuration as a heuristic tool to identify plausible causal configurations.SettingsSince 2000, the Ministry of Health in Morocco initiated many reforms in the frame of the governmental deconcentration process called ‘advanced regionalisation’. The implementation of these reforms is hampered by inadequate human resource management capacities of local health system managers. Yet, the National ‘Concours Qualité’, a national quality assurance programme implemented since 2007, demonstrated that there are many islands of excellence. We explore how leadership may play a role in explaining these islands of excellence.ParticipantsWe carried out a document review, 18 individual interviews and 3 group discussions (with doctors, administrators and nurses), and non-participant observations during a 2-week field visit in January–February 2018.ResultsWe confirmed that effective leaders adopt an appropriate mix of transactional, transformational and distributed leadership styles that fits the mission, goals, organisational culture and nature of tasks of the organisation and the individual characteristics of the personnel when organisational culture is conducive. Leadership effectiveness is conditioned by the degree of responsiveness to the basic psychological needs of autonomy, competence and relatedness, perceived organisational support and perceived supervisor support. Transactional and overcontrolling leadership behaviour decreased the satisfaction of the need for autonomy and mutual respect. By distributing leadership responsibilities, complex leaders create an enabling environment for collective efficacy and creative problem solving.ConclusionsWe found indications that in the Moroccan context, well-performing hospitals could be characterised by a good fit between leadership styles, organisational characteristics and individual staff attributes.

BackgroundDistrict health managers play a key role in the effectiveness of decentralized health systems in low- and middle-income countries. Inadequate management and leadership skills often hamper their ability to improve quality of care and effectiveness of health service delivery. Nevertheless, significant investments have been made in capacity-building programmes based on site-based training, mentoring, and operational research. This systematic review aims to review the effectiveness of site-based training, mentoring, and operational research (or action research) on the improvement of district health system management and leadership. Our secondary objectives are to assess whether variations in composition or intensity of the intervention influence its effectiveness and to identify enabling and constraining contexts and underlying mechanisms.MethodsWe will search the following databases: MEDLINE, PsycInfo, Cochrane Library, CRD database (DARE), Cochrane Effective Practice and Organisation of Care (EPOC) group, ISI Web of Science, Health Evidence.org, PDQ-Evidence, ERIC, EMBASE, and TRIP. Complementary search will be performed (hand-searching journals and citation and reference tracking).Studies that meet the following PICO (Population, Intervention, Comparison, Outcome) criteria will be included: P: professionals working at district health management level; I: site-based training with or without mentoring, or operational research; C: normal institutional arrangements; and O: district health management functions. We will include cluster randomized controlled trials, controlled before-and-after studies, interrupted time series analysis, quasi-experimental designs, and cohort and longitudinal studies. Qualitative research will be included to contextualize findings and identify barriers and facilitators.Primary outcomes that will be reported are district health management and leadership functions. We will assess risk of bias with the Cochrane Collaboration’s tools for randomized controlled trials (RCT) and non RCT studies and Critical Appraisal Skills Programme checklists for qualitative studies. We will assess strength of recommendations with the GRADE tool for quantitative studies, and the CERQual approach for qualitative studies. Synthesis of quantitative studies will be performed through meta-analysis when appropriate. Best fit framework synthesis will be used to synthesize qualitative studies.DiscussionThis protocol paper describes a systematic review assessing the effectiveness of site-based training (with or without mentoring programmes or operational research) on the improvement of district health system management and leadership.Systematic review registrationPROSPERO CRD42015032351Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-016-0239-z) contains supplementary material, which is available to authorized users.

BackgroundThe motivation of health workers is a key concern of policy makers, practitioners and researchers. Public Service Motivation (PSM), defined as the altruistic desire to serve the common interest, to serve others and to help patients and their families regardless of financial or external rewards, has been shown to be key to the performance of public servants. Yet, limited attention has been paid to this kind of motivation in health care settings in low- and middle-income countries. Little is known about PSM and its contextual specificity in the Moroccan health system. We set out to qualitatively explore the meaning of PSM and its expression among health workers in four public hospitals.MethodsWe adopted a multiple embedded case study design to explore PSM in two well-performing and two poor-performing hospitals. We carried out 68 individual interviews, eight focus group discussions and 11 group discussions with different cadres (doctors, administrators and nurses). We carried out thematic analysis using NVivo 10.ResultsOur analysis shows that public service motivation is a notion that seems natural to the health workers we interviewed. Daily interactions with patients catalysed health providers’ affective motives (compassion and self- sacrifice), a central element of PSM. It also provided them with job satisfaction aligned with their intrinsic motivation. Managers and administrative personnel express other PSM components: attraction to public policy making and commitment to public values. A striking result is that health workers expressed strong religious beliefs about expected rewards from God when properly serving patients.ConclusionThis study highlights the presence of PSM as a driver of motivation among health workers in four Moroccon hospitals, and the prominence of intrinsic motivation and compassion in the motivation of frontline health workers. Religious beliefs were found to shape the expression of PSM in Morocco.

BackgroundIn Morocco’s health systems, reforms were accompanied by increased tensions among doctors, nurses and health managers, poor interprofessional collaboration and counterproductive power struggles. However, little attention has focused on the processes underlying these interprofessional conflicts and their nature. Here, we explored the perspective of health workers and managers in four Moroccan hospitals.MethodsWe adopted a multiple embedded case study design and conducted 68 interviews, 8 focus group discussions and 11 group discussions with doctors, nurses, administrators and health managers at different organisational levels. We analysed what health workers (doctors and nurses) and health managers said about their sources of power, perceived roles and relationships with other healthcare professions. For our iterative qualitative data analysis, we coded all data sources using NVivo V.11 software and carried out thematic analysis using the concepts of ‘negotiated order’ and the four worldviews. For context, we used historical analysis to trace the development of medical and nursing professions during the colonial and postcolonial eras in Morocco.ResultsOur findings highlight professional hierarchies that counterbalance the power of formal hierarchies. Interprofessional interactions in Moroccan hospitals are marked by conflicts, power struggles and daily negotiated orders that may not serve the best interests of patients. The results confirm the dominance of medical specialists occupying the top of the professional hierarchy pyramid, as perceived at all levels in the four hospitals. In addition, health managers, lacking institutional backing, resources and decision spaces, often must rely on soft power when dealing with health workers to ensure smooth collaboration in care.ConclusionThe stratified order of care professions creates hierarchical professional boundaries in Moroccan hospitals, leading to partitioning of care and poor interprofessional collaboration. More attention should be placed on empowering health workers in delivering quality care by ensuring smooth interprofessional collaboration.