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Leadership capacity needs development and nurturing at all levels for strong health systems governance and improved outcomes. The Doctor of Public Health (DrPH) is a professional, interdisciplinary terminal degree focused on strategic leadership capacity building. The concept is not new and there are several programmes globally-but none within Africa, despite its urgent need for strong strategic leadership in health. To address this gap, a consortium of institutions in Sub-Saharan Africa, UK and North America have embarked on a collaboration to develop and implement a pan-African DrPH with support from the Rockefeller Foundation. This paper presents findings of research to verify relevance, identify competencies and support programme design and customization. A mixed methods cross sectional multi-country study was conducted in Ghana, South Africa and Uganda. Data collection involved a non-exhaustive desk review, 34 key informant (KI) interviews with past and present health sector leaders and a questionnaire with closed and open ended items administered to 271 potential DrPH trainees. Most study participants saw the concept of a pan-African DrPH as relevant and timely. Strategic leadership competencies identified by KI included providing vision and inspiration for the organization, core personal values and character qualities such as integrity and trustworthiness, skills in adapting to situations and context and creating and maintaining effective change and systems. There was consensus that programme design should emphasize learning by doing and application of theory to professional practice. Short residential periods for peer-to-peer and peer-to-facilitator engagement and learning, interspaced with facilitated workplace based learning, including coaching and mentoring, was the preferred model for programme implementation. The introduction of a pan-African DrPH with a focus on strategic leadership is relevant and timely. Core competencies, optimal design and customization for the sub-Saharan African context has broad consensus in the study setting.

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 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]

Objectives: To explore the “how” and “why” of care decision making by frontline providers of maternal and newborn services in the Greater Accra region of Ghana and determine appropriate interventions needed to support its quality and related maternal and neonatal outcomes. Methods: A cross sectional and descriptive mixed method study involving a desk review of maternal and newborn care protocols and guidelines availability, focus group discussions and administration of a structured questionnaire and observational checklist to frontline providers of maternal and newborn care. Results: Tacit knowledge or ‘mind lines’ was an important primary approach to care decision making. When available, protocols and guidelines were used as decision making aids, especially when they were simple handy tools and in situations where providers were not sure what their next step in management had to be. Expert opinion and peer consultation were also used through face to face discussions, phone calls, text messages, and occasional emails depending on the urgency and communication medium access. Health system constraints such as availability of staff, essential medicines, supplies and equipment; management issues (including leadership and interpersonal relations among staff), and barriers to referral were important influences in decision making. Frontline health providers welcomed the idea of interventions to support clinical decision making and made several proposals towards the development of such an intervention. They felt such an intervention ought to be multi-faceted to impact the multiple influences simultaneously. Effective interventions would also need to address immediate challenges as well as more long-term challenges influencing decision-making. Conclusion: Supporting frontline worker clinical decision making for maternal and newborn services is an important but neglected aspect of improved quality of care towards attainment of MDG 4 & 5. A multi-faceted intervention is probably the best way to make a difference given the multiple inter-related issues. [ABSTRACT FROM AUTHOR]