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Background: The need for locally-driven, locally-generated evidence to guide health policy and systems decision-making and implementation in West Africa remains urgent. Thus, health policy and systems research (HPSR) is a field with great potential for addressing many of the sub-region's intransigent health challenges. This paper presents an analysis of trends and patterns of peer-reviewed HPSR publications across the Economic Community of West African States (ECOWAS), to help understand trends and patterns of HPSR publication and the degree of involvement of West African researchers in HPSR evidence generation in the sub-region. Our goal was to use the findings to inform the development of a sub-regional strategy to strengthen HPSR and its use to inform development and improvement of health outcomes.Methods: A scoping review was conducted over a 25-year period from January 1990 to September 2015. Literature searches were conducted in English and French using Google Scholar, PubMed Central and Cairn.info.Results: A total of 258 articles were retrieved. Of these, 246 were statistically analysed, with 54% having West African lead authors. Two thirds of the papers originated from three out of the 15 countries of the ECOWAS, specifically Nigeria (28.86%), Burkina Faso (21.54%) and Ghana (17.07%). Most authors were based in academic institutions and participation of authors from ministries of health, hospitals and non-governmental organisations was limited. English was the predominant language for publication even for papers originating from Francophone West African countries. There has been a progressive increase in publications over the studied period.Conclusion: Despite progressive improvements over time, West Africa remains a weak sub-region in terms of peer-reviewed HPSR publications. Within the overall weakness, there is country-to-country variation. The fact that only a handful of countries accounted for nearly 70% of the total volume of publications in West Africa attests to the great disparities in individual, institutional and contextual capacities for HPSR evidence generation. Bridging the gap between lead institutions (universities and research centres) and the practice community (ministries, hospitals, non-governmental organisations) is indispensable for ensuring the practical use of HPSR evidence. There remains a major need for investments in HPSR capacity building in West Africa. [ABSTRACT FROM AUTHOR]

Introduction: The importance of accessible mental health treatment is a global concern, particularly when one in five people will experience a mental health problem in their lifespan. This is no less important in Ghana; however, no studies have yet attempted to appraise and synthesise the potential enablers and barriers to accessing services in Ghana. The aim of this integrative review is therefore to identify and synthesise existing evidence on the barriers and enablers to accessing mental health services in Ghana.Methods: A search of the published literature was conducted using Medline, EMBASE, PsycINFO, CINAHL (EBSCO), Web of Science, and Scopus electronic databases. The search was limited to papers published in English and within 2000-2018. Using pre-defined inclusion and exclusion criteria, two reviewers independently screened the titles and abstracts of the retrieved papers. A data extraction form and a Critical Appraisal Checklist were used to extract and appraise data, respectively. The integrative review incorporates both qualitative and quantitative data into a single synthesis.Results: Out of 42 papers that met the inclusion criteria, 50% used qualitative methods, 33.3% used mixed methods and 16.7% used quantitative methods alone. The potential barriers in accessing mental health services were attitudinal, knowledge about services, treatment cost, transportation and geographical proximity, as well as perceived efficacy of medication. Similarly, the health systems factors contributing to barriers were low priority, limited funding sources, irregular medicine supply, limited services for marginalised groups and poor state of psychiatric facilities, together with poor management of mental health cadres. The potential enablers for service users involved increased decentralisation and integration, task-shifting and existing support services.Conclusion: The existing evidence on mental health in Ghana is skewed towards weaknesses in the systems and stigma, with rationally little, or no, evidence or emphasis on the effectiveness, or quality of mental health services. These attributes largely neglect the provision of psychiatric services for marginalised mental health service user groups, including children, adolescents, people with disabilities and the elderly. [ABSTRACT FROM AUTHOR]

Background: Partnerships are increasingly common in conducting research. However, there is little published evidence about processes in research-policy partnerships in different contexts. This paper contributes to filling this gap by analysing experiences of research-policy partnerships between Ministries of Health and research organisations for the implementation of the Mental Health and Poverty Project in Ghana, South Africa, Uganda and Zambia. Methods: A conceptual framework for understanding and assessing research-policy partnerships was developed and guided this study. The data collection methods for this qualitative study included semi-structured interviews with Ministry of Health Partners (MOHPs) and Research Partners (RPs) in each country. Results: The term partnership was perceived by the partners as a collaboration involving mutually-agreed goals and objectives. The principles of trust, openness, equality and mutual respect were identified as constituting the core of partnerships. The MOHPs and RPs had clearly defined roles, with the MOHPs largely providing political support and RPs leading the research agenda. Different influences affected partnerships. At the individual level, personal relationships and ability to compromise within partnerships were seen as important. At the organisational level, the main influences included the degree of formalisation of roles and responsibilities and the internal structures and procedures affecting decision-making. At the contextual level, political environment and the degree of health system decentralisation affected partnerships. Conclusions: Several lessons can be learned from these experiences. Taking account of influences on the partnership at individual, organisation and contextual/system levels can increase its effectiveness. A common understanding of mutually-agreed goals and objectives of the partnership is essential. It is important to give attention to the processes of initiating and maintaining partnerships, based on clear roles, responsibilities and commitment of parties at different levels. Although partnerships are often established for a specific purpose, such as carrying out a particular project, the effects of partnership go beyond a particular initiative. [ABSTRACT FROM AUTHOR]

Background: In Ghana, the community-based health planning and services (CHPS) policy highlights the significance of both community health management committees (CHMCs) and community health volunteers (CHVs) in the Ghanaian health system. However, research into their specific effects on health system improvement is scarce. Some research has focussed on the roles of the CHMCs/CHVs in implementing specific targeted health interventions but not on improving the overall health system. Therefore, this research aims to examine the role of the CHMCs and CHVs in improving the Ghanaian health system. Methods: The study was conducted in three districts in the Ashanti region of Ghana. A total of 35 participants, mainly health service users and health professionals, participated in the study. Data were collected using semi-structured individual in-depth interviews. Participants were selected according to their patient–public engagement or community health activity roles. Data were transcribed and analysed descriptively using NVIVO 12 Plus. Results: We found that the effectiveness of CHMCs and CHVs in health systems improvement depends largely on how members are selected. Additionally, working through CHMC and CHVs improves resource availability for community health services, and using them in frontline community health activities improves health outcomes. Conclusions: Overall, we recommend that, for countries with limited healthcare resources such as Ghana, leveraging the significant role of the CHMCs and CHVs is key in complementing government's efforts to improve resource availability for healthcare services. Community health management committees and CHVs are key in providing basic support to communities with limited healthcare personnel. Thus, there is a need to strengthen their capacities to improve the overall health system. [ABSTRACT FROM AUTHOR]

Background: Quality improvement (QI) interventions are becoming more common in low- and middle-income countries, yet few studies have presented impact evaluations of these approaches. In this paper, we present an impact evaluation of a scale-up phase of 'Project Fives Alive!', a QI intervention in Ghana that aims to improve maternal and child health outcomes. 'Project Fives Alive!' employed a QI methodology to recognize barriers to care-seeking and care provision at the facility level and then to identify, test and implement simple and low-cost local solutions that address the barriers.Methods: A quasi-experimental design, multivariable interrupted time series analysis, with data coming from 744 health facilities and controlling for potential confounding factors, was used to study the effect of the project. The key independent variables were the change categories (interventions implemented) and implementation phase - Wave 2a (early phase) versus Wave 2b (later phase). The outcomes studied were early antenatal care (ANC), skilled delivery, facility-level under-five mortality and attendance of underweight infants at child welfare clinics. We stratified the analysis by facility type, namely health posts, health centres and hospitals.Results: Several of the specific change categories were significantly associated with improved outcomes. For example, three of five change categories (early ANC, four or more ANC visits and skilled delivery/immediate postnatal care (PNC)) for health posts and two of five change categories (health education and triage) for hospitals were associated with increased skilled delivery. These change categories were associated with increases in skilled delivery varying from 28% to 58%. PNC changes for health posts and health centres were associated with greater attendance of underweight infants at child welfare clinics. The triage change category was associated with increased early antenatal care in hospitals. Intensity, the number of change categories tested, was associated with increased skilled delivery in health centres and reduced under-five mortality in hospitals.Conclusions: Using an innovative evaluation technique we determined that 'Project Fives Alive!' demonstrated impact at scale for the outcomes studied. The QI approach used by this project should be considered by other low- and middle-income countries in their efforts to improve maternal and child health. [ABSTRACT FROM AUTHOR]

Background: Development of health policy is a complex process that does not necessarily follow a particular format and a predictable trajectory. Therefore, agenda setting and selecting of alternatives are critical processes of policy development and can give insights into how and why policies are made. Understanding why some policy issues remain and are maintained whiles others drop off the agenda is an important enquiry. This paper aims to advance understanding of health policy agenda setting and formulation in Ghana, a lower middle-income country, by exploring how and why the maternal (antenatal, delivery and postnatal) fee exemption policy agenda in the health sector has been maintained over the four and half decades since a 'free antenatal care in government facilities' policy was first introduced in October 1963. Methods: A mix of historical and contemporary qualitative case studies of nine policy agenda setting and formulation processes was used. Data collection methods involved reviews of archival materials, contemporary records, media content, in-depth interviews, and participant observation. Data was analysed drawing on a combination of policy analysis theories and frameworks. Results: Contextual factors, acting in an interrelating manner, shaped how policy actors acted in a timely manner and closely linked policy content to the intended agenda. Contextual factors that served as bases for the policymaking process were: political ideology, economic crisis, data about health outcomes, historical events, social unrest, change in government, election year, austerity measures, and international agendas. Nkrumah's socialist ideology first set the agenda for free antenatal service in 1963. This policy trajectory taken in 1963 was not reversed by subsequent policy actors because contextual factors and policy actors created a network of influence to maintain this issue on the agenda. Politicians over the years participated in the process to direct and approve the agenda. Donors increasingly gained agenda access within the Ghanaian health sector as they used financial support as leverage. Conclusion: Influencers of policy agenda setting must recognise that the process is complex and intertwined with a mix of political, evidence-based, finance-based, path-dependent, and donor-driven processes. Therefore, influencers need to pay attention to context and policy actors in any strategy. [ABSTRACT FROM AUTHOR]

Background Although there is widespread agreement that strong district manager decision-making improves health systems, understanding about how the design and implementation of capacity-strengthening interventions work is limited. The Ghana Health Service has adopted the Leadership Development Programme (LDP) as one intervention to support the development of management and leadership within district teams. This paper seeks to address how and why the LDP 'works' when it is introduced into a district health system in Ghana, and whether or not it supports systems thinking in district teams. Methods We undertook a realist evaluation to investigate the outcomes, contexts, and mechanisms of the intervention. Building on two working hypotheses developed from our earlier work, we developed an explanatory case study of one rural district in the Greater Accra Region of Ghana. Data collection included participant observation, document review, and semistructured interviews with district managers prior to, during, and after the intervention. Working backwards from an in-depth analysis of the context and observed short- and medium-term outcomes, we drew a causal loop diagram to explain interactions between contexts, outcomes, and mechanisms. Results The LDP was a valuable experience for district managers and teams were able to attain short-term outcomes because the novel approach supported teamwork, initiative-building, and improved prioritisation. However, the LDP was not institutionalised in district teams and did not lead to increased systems thinking. This was related to the context of high uncertainty within the district, and hierarchical authority of the system, which triggered the LDP's underlying goal of organisational control. Conclusions Consideration of organisational context is important when trying to sustain complex interventions, as it seems to influence the gap between short- and medium-term outcomes. More explicit focus on systems thinking principles that enable district managers to better cope with their contexts may strengthen the institutionalisation of the LDP in the future. [ABSTRACT FROM AUTHOR]

Background: The paper carries out a situational analysis to examine the production, dissemination and utilisation of reproductive and child health-related evidence to inform policy formulation in Ghana's health sector.Methods: The study used Wald's model of knowledge production, transfer and utilisation as a conceptual model to collect relevant data via interviews and administration of questionnaire to a network of persons who either previously or currently hold policy-relevant positions in Ghana's health sector. Additional data was also gathered through a scoping review of the knowledge transfer and research utilisation literature, existing reproductive and child health policies, protocols and guidelines and information available on the websites of relevant institutions in Ghana's health sector.Results: The findings of the study suggest that the health sector in Ghana has major strengths (strong knowledge production capacity, a positive environment for the promotion of evidence-informed policy) and opportunities (access to major donors who have the resources to fund good quality research and access to both local and international networks for collaborative research). What remains a challenge, however, is the absence of a robust institutional-wide mechanism for collating research needs and communicating these to researchers, communicating research findings in forms that are friendlier to policy-makers and the inability to incorporate funding for research into the budget of the health sector.Conclusion: The study concludes, admonishing the Ministry of Health and its agencies to leverage on the existing strengths and opportunities to address the identified challenges. [ABSTRACT FROM AUTHOR]

Background: The Joint United Nations Programme on HIV/AIDS launched the 90-90-90 initiative. Failure to meet the target reflects the difficulties in successfully implementing HIV treatment policy. There are research gaps in exploring personal and external factors influencing HIV treatment in Ghana. To fill this gap, we explored individual and environmental (interpersonal, community and structural) factors influencing stakeholders' HIV treatment policy implementation in Ghana. Methods: Fifteen qualitative semi-structured in-depth interviews were conducted among representatives in different management positions at hospitals, health directorates, the Ghana AIDS Commission, the National AIDS and STI control program, and the National Association of People Living with HIV. Results: Using thematic analysis, the findings suggest that individual and environmental factors such as attitude towards policy, awareness of HIV treatment policy, training received on policy implementation, difficulties related to patient factors, alternate sources of HIV care, inefficient policy decision-making, monitoring and evaluation of HIV treatment policy, lack of HIV treatment policy implementation training, poor availability of logistics, policy and guidelines, infrastructure, organization of training, and staff availability may hinder successful HIV treatment policy implementation. Conclusion: Several individual and environmental (interpersonal, community and structural) factors seem to influence HIV treatment policy implementation. To ensure successful policy implementation stakeholders need to receive training on new policies, availability of sufficient supplies of material resources, inclusive decision-making, receive supportive monitoring of policy implementation, and oversight. [ABSTRACT FROM AUTHOR]

Background: Ghana became the first African country to take delivery of the first wave of the AstraZeneca/Oxford vaccine from the COVAX facility. But why has this promising start of the vaccination rollout not translated into an accelerated full vaccination of the population? To answer this question, we drew on the tenets of a policy analytical framework and analysed the diverse interpretations, issue characteristics, actor power dynamics and political context of the COVID-19 vaccination process in Ghana.Methods: We conducted a rapid online review of media reports, journal articles and other documents on debates and discussions of issues related to framing of the vaccination rollout, social constructions generated around vaccines, stakeholder power dynamics and political contentions linked to the vaccination rollout. These were complemented by desk reviews of parliamentary reports.Results: The COVID-19 vaccination was mainly framed along the lines of public health, gender-centredness and universal health coverage. Vaccine acquisition and procurement were riddled with politics between the ruling government and the largest main opposition party. While the latter persistently blamed the former for engaging in political rhetoric rather than a tactical response to vaccine supply issues, the former attributed vaccine shortages to vaccine nationalism that crowded out fair distribution. The government's efforts to increase vaccination coverage to target levels were stifled when a deal with a private supplier to procure 3.4 million doses of the Sputnik V vaccine collapsed due to procurement breaches. Amidst the vaccine scarcity, the government developed a working proposal to produce vaccines locally which attracted considerable interest among pharmaceutical manufacturers, political constituents and donor partners. Regarding issue characteristics of the vaccination, hesitancy for vaccination linked to misperceptions of vaccine safety provoked politically led vaccination campaigns to induce vaccine acceptance.Conclusions: Scaling up vaccination requires political unity, cohesive frames, management of stakeholder interests and influence, and tackling contextual factors promoting vaccination hesitancy. [ABSTRACT FROM AUTHOR]

Background: Understanding decision-making processes that influence the fate of items on the health policy agenda at national level in low- and middle-income countries is important because of the implications for programmes and outcomes. This paper seeks to advance our understanding of these processes by asking how and why maternal health policy agenda items have fared in Ghana between 1963 and 2014.Methods: The study design was a single case study of maternal health agenda evolution once on a decision pathway in Ghana, with three different agenda items as sub-units of analysis (fee exemptions for maternal health, free family planning and primary maternal health as part of a per capita provider payment system). Data analysis involved chronologically reconstructing how maternal health policy items evolved over time.Results: The fate of national level maternal health policy items was heavily influenced by how stakeholders (bureaucrats, professional bodies, general public and developmental partners) exercised power to put forward and advocate for specific ideas through processes of issues framing within a changing political and socioeconomic context. The evolution and fate of an agenda item once on a decision pathway involved an iterative process of interacting drivers shaping decisions through cycles of 'active' and 'static' pathways. Items could move from 'active' to 'static' pathways, depending on changing context and actor positions. Items that pursued the 'static' pathway in a particular cycle fell into obscurity by a process that could be described as a form of 'no decision made' in that an explicit decision was not taken to drop the item, but neither was any policy content agreed. Low political interest was exhibited and attempts to bring the item back into active decision-making were made by actors mainly in the bureaucratic arena seeking and struggling (unsuccessfully) to obtain financial and institutional support. Policy items that pursued 'active' pathways showed opposite characteristics and generally moved beyond agenda into formulation and implementation.Conclusion: Policy change requires sustaining policy agenda items into formulation and implementation. To do this, change agents need to understand and work within the relevant context, stakeholder interests, power, ideas and framing of issues. [ABSTRACT FROM AUTHOR]

Background: Assessing the performance of health systems through quantitative and qualitative methods is recognized as an effective approach to strengthening national health systems. However, while many high-income countries have institutionalized health system performance assessment (HSPA) as an integral component of their respective health systems, few studies on HSPA have been documented in low- and middle-income countries, including Ghana. This study aims at providing a comprehensive framework for periodic assessment of the performance of the entire health system in Ghana.Methods: The study will have four work packages. First, a structured review will be conducted to identify both international and national HSPA frameworks that could be applied to the Ghanaian context. Second, based on the structured review, an assessment framework tailored to the Ghanaian health system context will be developed. Third, the draft framework will be presented and discussed with experts and stakeholders for its appropriateness, feasibility and acceptability. Finally, the framework will be piloted to assess its effectiveness and suitability for full-scale implementation.Discussion: Currently, Ghana does not have a full-fledged HSPA tool that provides a holistic health sector-wide approach to assessing health system performance. Thus, developing this HSPA framework for the country will provide a tool for periodic and comprehensive assessment of the performance of the health system, which can be compared with that of other countries. Such a comparison will offer the opportunity for mutual learning and for exploring new options for formulating more effective national health policies. As this is expected to be the first attempt to develop a comprehensive HSPA framework in Ghana, this study will provide a basis for future discussions on how to further develop and implement HSPA programmes in the country. [ABSTRACT FROM AUTHOR]

Background: Licences to operate pharmacy premises are issued by statutory regulatory bodies. The Health Institutions and Facilities Act (Act 829) and Health Professions Regulatory Bodies Act (Act 857) regulate pharmacy premises and the business of supplying restricted medicines by retail, respectively, and this could create a potential regulatory overlap for pharmacy practice in Ghana. We theorise that the potential overlap of regulation duties stems from how law-makers framed issues and narratives during the formulation of these Acts.Objective: To describe the policy actors involved, framing of narratives and decision-making processes relating to pharmacy premises licensing policy formulation.Methods: A qualitative study was conducted and data gathered through interviewing eight key informants and reviewing Hansards, reports, bills, memoranda and Acts 829 and 857. Data were analysed to map decision-making venues, processes, actors and narratives.Results: The Ministry of Health drafted the bills in July 2010 with the consensus of internal stakeholders. These were interrogated by the Parliament Select Committee on Health (with legislative power) during separate periods, and decisions made in Parliament to alter propositions of pharmacy premises regulations. Parliamentarians framed pharmacies as health facilities and reassigned their regulation from the Pharmacy Council to a new agency. The Pharmacy Council and the Pharmaceutical Society of Ghana could not participate in the decision-making processes in Parliament to oppose these alterations. The laws' contents rested with parliamentarians as they made decisions in venues restricted to others. Legislative procedure limited participation, although non-legislative actors had some level of influence on the initial content.Conclusion: Implementation of these laws would have implications for policy and practice and therefore understanding how the laws were framed and formulated is important for further reforms. We recommend additional research to investigate the impact of the implementation of these Acts on pharmacy practice and business in Ghana and the findings can serve as bargaining information for reforms. [ABSTRACT FROM AUTHOR]

Background: Evidence-based decision-making is crucial to leadership in the health sector to identify country-level priorities and generate solutions supported by rigorous research. Barriers and enablers have been explored, but limited evidence about what works to strengthening capacity at individual and institutional levels within countries has been reported, and inconsistent use of evidence to inform policy-making is a persistent challenge and concern.Methods: We conducted a framework analysis comparing experiences of nine purposively selected countries (Chile, Ethiopia, Ghana, Kyrgyzstan, Lebanon, Mozambique, Rwanda, South Africa and Sri Lanka). We utilised qualitative case studies developed by in-country teams to explore enablers and barriers described across components of a predefined theory of change and then identified six cross-cutting themes and recommendations for relevant stakeholders associated with each theme.Results: The cross-cutting themes included (1) leadership and political will, (2) incentives and resources, (3) infrastructure and access to health data, (4) designated structures and processes, (5) interaction and relationships, and (6) capacity strengthening and engagement. While each case country's context and experience was different, common enablers and barriers surfaced across each of these themes, with Ministries of Health and other government agencies having strong roles to play, but also recognising the need for other stakeholders, including researchers, donors and civil society, to serve as essential collaborators in order to strengthen evidence uptake. Substantial and sustained investment in research capacities, able leaders and stronger engagement of civil servants are needed to further this progress and strengthen processes of health decision-making.Conclusions: All countries represented in this study have made commendable progress in increasing evidence uptake and strengthening supportive systems. Establishing and strengthening necessary structures and the relationships that underpin them takes time as well as resources. Going forward, the findings from this study can help guide and support advocacy to increase domestic funding for health research, especially health policy and systems research, and ensure that civil servants as well as researchers have the capacity and support to collaborate and continue to bolster evidence uptake. [ABSTRACT FROM AUTHOR]

Background: Evidence-based decision-making for prioritising health is assisted by health technology assessment (HTA) to integrate data on effectiveness, costs and equity to support transparent decisions. Ghana is moving towards universal health coverage, facilitated mainly by the National Health Insurance Scheme (NHIS) established in 2003. The Government of Ghana is committed to institutionalising HTA for priority-setting. We aimed to identify and describe the sources of accessible data to support HTA in Ghana.Methods: We identified and described data sources encompassing six main domains using an existing framework. The domains were epidemiology, clinical efficacy, costs, health service use and consumption, quality of life, and equity. We used existing knowledge, views of stakeholders, and searches of the literature and internet.Results: The data sources for each of the six domains vary in extent and quality. Ghana has several large data sources to support HTA (e.g. Demographic Health Surveys) that have rigorous quality assurance processes. Few accessible data sources were available for costs and resource utilisation. The NHIS is a potentially rich source of data on resource use and costs but there are some limits on access. There are some data on equity but data on quality of life are limited.Conclusions: A small number of quality data sources are available in Ghana but there are some gaps with respect to HTA based on greater use of local and contextualised information. Although more data are becoming available for monitoring, challenges remain in terms of their usefulness for HTA, and some information may not be available in disaggregated form to enable specific analyses. We support recent initiatives for the routine collection of comprehensive and reliable data that is easily accessible for HTA users. A commitment to HTA will require concerted efforts to leverage existing data sources, for example, from the NHIS, and develop and maintain new data (e.g. local health utility estimates). It will be critical that an overarching strategic and mandatory approach to the collection and use of health information is developed for Ghana in parallel to, and informed by, the development of HTA approaches to support resource allocation decisions. The key to HTA is to use the best available data while being open about its limitations and the impact on uncertainty. [ABSTRACT FROM AUTHOR]

Background: At the turn of the 90s, studies showed that health research contributed little to health and development in low- and middle-income countries because it was oriented towards international priorities and dominated by researchers from the North. A new approach to North-South collaboration was required that would support demand-driven and locally led research in the South. The aim of this study was to analyse the development and functioning of a programme for demand-driven and locally led research in Ghana that was supported by a North-South collaboration.Methods: For this mixed-method case study, we combined document analysis, key informant interviews and observation of programme events.Results: The development of the research programme started with constructing a sponsorship constellation in the Netherlands. After highlighting the problems with traditional research collaboration, an advisory council formulated a vision for a more equal and effective approach to North-South collaboration. Together with Ghanaian partners, this vision was turned into a proposal for a Ghanaian-led programme for demand-driven and locally led research, which was funded by the Netherlands government. Research priority setting showed that the Ghanaian research needs were very different from the priorities of foreign funders and researchers. After a slow start, the number of locally submitted proposals increased from 13 in 2001 to 94 in 2005, revealing the existence of a substantial, but partly latent reservoir of research capacity. In total, 79 studies were funded. An impact evaluation showed that the results of the majority of the studies were used to contribute to action. Despite its success, the research programme came to an end in 2008 after the sponsorship constellation in the Netherlands fell apart.Conclusion: Our study shows that realising a programme for demand-driven and locally led research in the South provides an effective approach to North-South collaboration in which results are used and local capacities and institutions are strengthened. [ABSTRACT FROM AUTHOR]

Background: Despite improvements over time, West Africa lags behind global as well as sub-Saharan averages in its maternal, newborn and child health (MNCH) outcomes. This is despite the availability of an increasing body of knowledge on interventions that improve such outcomes. Beyond our knowledge of what interventions work, insights are needed on others factors that facilitate or inhibit MNCH outcome improvement. This study aimed to explore health system factors conducive or limiting to MNCH policy and programme implementation and outcomes in West Africa, and how and why they work in context.Methods: We conducted a mixed methods multi-country case study focusing predominantly, but not exclusively, on the six West African countries (Burkina Faso, Benin, Mali, Senegal, Nigeria and Ghana) of the Innovating for Maternal and Child Health in Africa initiative. Data collection involved non-exhaustive review of grey and published literature, and 48 key informant interviews. We validated our findings and conclusions at two separate multi-stakeholder meetings organised by the West African Health Organization. To guide our data collection and analysis, we developed a unique theoretical framework of the link between health systems and MNCH, in which we conceptualised health systems as the foundations, pillars and roofing of a shelter for MNCH, and context as the ground on which the foundation is laid.Results: A multitude of MNCH policies and interventions were being piloted, researched or implemented at scale in the sub-region, most of which faced multiple interacting conducive and limiting health system factors to effective implementation, as well as contextual challenges. Context acted through its effect on health system factors as well as on the social determinants of health.Conclusions: To accelerate and sustain improvements in MNCH outcomes in West Africa, an integrated approach to research and practice of simultaneously addressing health systems and contextual factors alongside MNCH service delivery interventions is needed. This requires multi-level, multi-sectoral and multi-stakeholder engagement approaches that span current geographical, language, research and practice community boundaries in West Africa, and effectively link the efforts of actors interested in health systems strengthening with those of actors interested in MNCH outcome improvement. [ABSTRACT FROM AUTHOR]

Background: While health research is considered essential for improving health worldwide, it remains unclear how it is best organized to contribute to health. This study examined research that was part of a Ghanaian-Dutch research program that aimed to increase the likelihood that results would be used by funding research that focused on national research priorities and was led by local researchers. The aim of this study was to map the contribution of this research to action and examine which features of research and translation processes were associated with the use of the results.Methods: Using Contribution Mapping, we systematically examined how 30 studies evolved and how results were used to contribute to action. We combined interviews with 113 purposively selected key informants, document analysis and triangulation to map how research and translation processes evolved and contributions to action were realized. After each case was analysed separately, a cross-case analysis was conducted to identify patterns in the association between features of research processes and the use of research.Results: The results of 20 of the 30 studies were used to contribute to action within 12 months. The priority setting and proposal selection process led to the funding of studies which were from the outset closely aligned with health sector priorities. Research was most likely to be used when it was initiated and conducted by people who were in a position to use their results in their own work. The results of 17 out of 18 of these user-initiated studies were translated into action. Other features of research that appeared to contribute to its use were involving potential key users in formulating proposals and developing recommendations.Conclusions: Our study underlines the importance of supporting research that meets locally-expressed needs and that is led by people embedded in the contexts in which results can be used. Supporting the involvement of health sector professionals in the design, conduct and interpretation of research appears to be an especially worthwhile investment. [ABSTRACT FROM AUTHOR]

Background: Unsafe abortion is a major public health problem in Ghana; despite its liberal abortion law, access to safe, legal abortion in public health facilities is limited. Theory is often neglected as a tool for providing evidence to inform better practice; in this study we investigated the reasons for poor implementation of the policy in Ghana using Lipsky's theory of street-level bureaucracy to better understand how providers shape and implement policy and how provider-level barriers might be overcome. Methods: In-depth interviews were conducted with 43 health professionals of different levels (managers, obstetricians, midwives) at three hospitals in Accra, as well as staff from smaller and private sector facilities. Relevant policy and related documents were also analysed. Results: Findings confirm that health providers' views shape provision of safe-abortion services. Most prominently, providers experience conflicts between their religious and moral beliefs about the sanctity of (foetal) life and their duty to provide safe-abortion care. Obstetricians were more exposed to international debates, treaties, and safe-abortion practices and had better awareness of national research on the public health implications of unsafe abortions; these factors tempered their religious views. Midwives were more driven by fundamental religious values condemning abortion as sinful. In addition to personal views and dilemmas, 'social pressures' (perceived views of others concerning abortion) and the actions of facility managers affected providers' decision to (openly) provide abortion services. In order to achieve a workable balance between these pressures and duties, providers use their 'discretion' in deciding if and when to provide abortion services, and develop 'coping mechanisms' which impede implementation of abortion policy. Conclusions: The application of theory confirmed its utility in a lower-middle income setting and expanded its scope by showing that provider values and attitudes (not just resource constraints) modify providers' implementation of policy; moreover their power of modification is constrained by organisational hierarchies and mid-level managers. We also revealed differing responses of 'front line workers' regarding the pressures they face; whilst midwives are seen globally as providers of safe-abortion services, in Ghana the midwife cadre displays more negative attitudes towards them than doctors. These findings allow the identification of recommendations for evidence-based practice. [ABSTRACT FROM AUTHOR]