HeAlth System StrEngThening in four sub_Saharan African countries (ASSET) to achieve high-quality, evidence-informed surgical, maternal and newborn, and primary care: protocol for pre-implementation phase studies

Abstract

ObjectivesTo achieve universal health coverage, health systems need to be strengthened to support the consistent delivery of high-quality, evidence-informed care at scale. The aim of the National Institute for Health Research (NIHR) Global Research Unit on HeAlth System StrEngThening in Sub-Saharan Africa (ASSET) is to address this need in a four-year programme spanning three healthcare platforms (primary health care for the integrated treatment of chronic conditions in adults, maternal and newborn, surgical care) involving eight work packages. This paper describes the pre-implementation phase research protocols that assess: (1) barriers to accessing care; (2) health system bottlenecks in care process and pathways; (3) quality of care, and; (4) people centredness. Findings from this research are used to engage stakeholders and to inform the selection of a set of health system strengthening interventions (HSSIs) and subsequent methodology for evaluation.SettingsPublicly funded health systems in rural and urban areas in Ethiopia, Sierra Leone, South Africa, and Zimbabwe.PopulationStakeholders including patients and their caregivers, community representatives, clinicians, managers, administrators, and policymakers.Study methodologies and deliveryIn each work package, we apply a mixed-methods approach, including: literature reviews; situation analyses; cohort studies; cross-sectional surveys; ethnographic observations; semi-structured interviews, and; focus group discussions. At the end of the pre-implementation phase, findings are fed back to stakeholders in participatory theory of change workshops that are used to select/adapt an initial set of contextually relevant HSSIs. To ensure a theory-informed approach across ASSET, implementation science determinant frameworks are also applied, to help identify any additional contextual barriers and enablers and complementary HSSIs. Outputs from these activities are used to finalise underlying assumptions, potential unintended consequences, process indicators and implementation and clinical outcomes.ConclusionsASSET places a strong emphasis of the pre-implementation phase of the programme in order to provide an in-depth and systematic diagnosis of the existing heath system functioning, needs for strengthening and active stakeholder engagement. This approach will inform the design and evaluation of the HSSIs to increase effectiveness across work packages and contexts, to better understand what works, for whom, and how.Strengths and limitations of this studyThe National Health Institute of Research (NIHR) Global Research Unit on Health System Strengthening in sub-Saharan Africa (ASSET) is a four-year programme (2017-2021) that is closely aligned with the SDG goal of UHC, and the recommendations of the Lancet Commission for High Quality Health Systems.The aim of ASSET is to develop and evaluate effective and sustainable HSSIs, promoting consistent delivery of high-quality, people-centred care.The ASSET programme is being conducted in two phases including the diagnostic pre-implementation and piloting/rolling implementation phase.The purpose of this paper is to describe the methodology for the pre-implementation phase, which has the core aim of mapping comprehensive care pathways of a patient’s journey though the health system including the community, different providers), and health facilities, documenting what care is provided at what level of the health system and the associated health system bottlenecks.At the end of the pre-implementation phase of ASSET, it is hoped the common approach taken across different countries, care platforms and health conditions will facilitate cross platform learning and understanding of how differences in health systems and broader contextual influences shaped the development of the interventions.The overarching expectation is that by using an in-depth participatory process to engage with the stakeholders and map care pathways to and through the health system, we develop a HSS programme that can be implemented at scale that meets the needs and priorities of the local community.

A guide to systems-level, participatory, theory-informed implementation research in global health

“…and address contextual and behavioural barriers and/or enablers to implement evidence-informed practice. 26 At the end of the preimplementation phase, a diverse group of stakeholders meet to review the findings, select an initial set of implementation strategies, and develop an initial programme theory (based on the theoretical approach taken) that details the causal processes of how the implementation strategies are expected to achieve the desired outcomes. This process can help to ensure appropriate methods are selected and relevant information is collected throughout the implementation and evaluation phase of research.…”

“…Our guidance, including the cited literature, is based on our expertise in the following multicountry implementation research programmes: Programme for Improving Mental Health care (PRIME), 20–23 a consortium of research institutions and ministries of health in five LMICs that implemented and expanded coverage of treatment for mental health conditions in primary care and community settings; the Emerging Mental Health Systems in LMICs (EMERALD) programme 24 25 ; and a multicountry heAlth Systems StrEngThening programme guided by implementation research and implementation science in sub-Saharan Africa (ASSET). 26 27 We also have experience with participatory research including participatory learning and action (PLA) with women’s groups to improve maternal and newborn health outcomes 28 29 and human-centred design to improve perinatal mental health outcomes. 30 We aim to use our experience to offer a relatively brief, user-focused guide to help global health actors recognise the important contributions arising from the different theoretical approaches and other methods to implement and report on evaluation of evidence-based and scalable interventions, programmes and practices.…”

“…The preimplementation phase is a critical phase that identifies the overall aim of the study and the main theoretical approach and subsequent methodology. 26 It is also useful at this stage to identify specific objectives that may indicate an additional theory-based approach is required. Key to this phase of research is engaging with stakeholders who are a part of the public health system to ensure that the research objectives address the needs and priorities of the local population.…”

“…5 33 This phase of research also requires involving stakeholders to conduct a careful assessment of the local context to understand and address contextual and behavioural barriers and/or enablers to implement evidence-informed practice. 26 …”

HeAlth System StrEngThening in four sub-Saharan African countries (ASSET) to achieve high-quality, evidence-informed surgical, maternal and newborn, and primary care: protocol for pre-implementation phase studies

“…We then review how findings are used to inform the selection and adaptation of contextually relevant HSS intervention. We also describe the synthesis of work package activities to draw conclusions on the general requirements of the health system to deliver high-quality people-centred care in LMICs [ 15 ]. To enable reproduction of individual work packages, protocols for the pre-implementation phase of ASSET are reported in Appendix 1.…”