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In the context of addressing challenges relating to ongoing interpersonal violence, this article conducts a comparative analysis of findings from a community asset mapping process drawing responses from 100 community participants across the two sites of Erijaville, South Africa and Memphis, Tennessee in the USA. Specifically, we describe the similarities and differences across sites regarding community assets linked to safety and peace promotion, with a particular emphasis on tangible and intangible factors relevant to the promotion of safety and peace. The findings reveal a major emphasis on ‘intangible’ factors that relate to the promotion of safety and peace, including personal values and behaviour (such as love, compassion and prayer), family relationships (such as family socialisation, care and supervision, role modelling, and peer guidance), and community connectedness (including community hope and trust, and the development of ethical leadership). The findings suggest that religious assets and spiritual capacity constitute important resources, which should be more intentionally mobilised and enhanced to promote safety and peace. This constitutes an important challenge in relation to violence prevention in both South Africa and the USA.Keywords: community-based participatory research, community asset mapping, interpersonal violence, violence prevention, positive forms of masculinity, peace and safety, religious assets, spiritual capacity

A social network sketch. This is a tool that was used to establish accountability linkages. (PDF 77Â kb)

Public-Private Partnership Policy Actor Map â September 2014. This map shows all actors in the district, and their position as related to PPP. (PDF 111Â kb)

Market share estimates—typically in the 30 percent to 40 percent range—are frequently wielded as the most concrete evidence of faith-inspired activity and impact in the area of health care provision in Sub-Saharan Africa. In fact, there are few speeches, reports, or articles that do not make some mention of market share, attaching some percentage to the significance of faith-inspired healthcare provision in the continent as a whole, or in specific countries. Such statements usually appear in the early stages of a text, and are the basis on which a further argument is made, for example that this sector therefore requires further attention or resources from governments and donors. A systematic review of this literature reveals that these statements have currently reached the point of becoming almost indisputable “truth,” as they are now frequently made without any referencing.

This paper has two objectives. The first is to provide a review of the discourses about the religious response to HIV/AIDS in Africa that have emerged from the recent literature, how these discourses has changed over time (from religiophobia to a cautious recognition of the comparative value of faith-inspired interventions), and the conflicting typologies of faith-inspired initiatives that they have inspired. Noting the limits of the existing typologies, the second objective is to suggest conceptually some of the ways in which typologies could be combined in order to be made more useful from an operational point of view.

This paper relies on facilities and household survey data to estimate the ‘market share’ of faith-inspired institutions (FIIs) in the provision of health care services in Africa. While estimates based on facilities data, especially for hospitals, often suggest that the market share of FIIs is at 30 percent to 40 percent, estimates from household surveys are typically at less than ten percent. A number of potential explanations for these large differences are provided. Both types of estimates suffer from limits, but observing the two types of estimates alongside one other provides a more balanced view of the market share of FIIs in health care systems as a whole than is the case for any single type of measure.

Christian Health Associations (CHAs) – umbrella networks of faith-inspired health providers – have become a solid presence in the collaborative environment of African health systems. Established through sometimes trial-and-error attempts to draw together disparate faith-based health providers who were disconnected from each other, and also unaligned with national health systems, CHAs have evolved into a particular kind of collaborative effort with a very specific role. CHAs now network faith-inspired health providers and facilities; advocate for a proper recognition of their work; negotiate with governments; build capacity among members; and in some cases now channel and report on substantive funds. In this paper we provide a brief recounting of the history of the CHAs and how they were established, as well as a basic typology of CHAs according to three (highly stylized) conceptual stages of their development. This is followed by a discussion of some of the challenges facing CHAs today, based on self-reports from the CHAs.

Patient service satisfaction has become a critical concept, utilized both in the assessment of quality of care and to predict a range of health-related behaviors and outcomes. What can be said about patient satisfaction with faith-inspired institutions (FIIs) in the African context in comparison with other providers, and especially public providers? Our objective in this paper is first to review what evidence there is in the literature that might cast light on the comparative satisfaction of patients with FII-health services in Africa today. Second, we present new evidence from household surveys in six African countries on satisfaction rates. Overall, the results suggest that satisfaction with the services provided by FIIs is higher than with those provided by public facilities.

This paper considers the evidence on the comparative extent to which faith-based civil society organizations (FB-CSOs) have benefited from increased funding related to the HIV/AIDS response in Africa. First, we review the literature on whether FB-CSOs have benefited from such funding, and find the arguments vigorous, but the evidence inconclusive. Next, we rely on a survey carried out in six Southern African countries to compare the profile and sources of funding of FB-CSOs against the broader collection of CSOs (non-religious or ‘secular’). It is important to be aware of the at times artificial distinctions made between faith-based and ‘secular’ structures, given the often integrated presence of religion in the lives of civil society actors and their institutions – especially in Africa. However, it is still useful to consider this particular distinction – impacting as it does on current policy discussions and strategies for civil society engagement. While the data of this particular study is mostly representative of a cluster of well-established ‘CSOs’, the evidence suggests that these FB-CSOs have been able to benefit as much as other CSOs from enhanced funding opportunities. We conclude, with a discussion of the challenges that remain for supporting smaller and less formal FB-CSOs and initiatives operating at a local community level.

This paper presents a framework for analyzing the community response to HIV and AIDS. On the basis of a review of the literature, six criteria are proposed for characterizing such community responses: (1) the types of organizations and structures implementing the response, (2) the types of activities or services implemented and the beneficiaries of these, (3) the actors involved in and driving community responses, (4) the contextual factors that influence community responses, (5) the extent of community involvement in the response, and (6) the extent to which community responses involve wider partnerships and collaboration.

Includes bibliographical references (leaves 204-223)., This exploratory study applies a cultural studies and interdisciplinary approach to the discourses that emerge in the discursive gap at the interface of religion and public health, a gap most readily seen in the context of HIV/AIDS and in literature addressing sub-Saharan Africa. The combination of the different, often divergent discursive frameworks of religion and public health, and the idea of the linguistic construction of HIV/AIDS, prompts this theoretical response. The empirical data for developing these theoretical judgements are based on personal involvement in the African Religious Health Assets Programme (ARHAP), an international, multi-institutional research collaborative that is focused on the intersection between religion and public health.

Includes bibliographical references., Do discourses of "hope" have real and practical consequences when it come to crucial issues such as policy, prevention, stigma, risk perception or funding? The following exploratory and treansdisciplinary study seeks to pull together a wide variety of the theoretical and analytical stances in order to examine the social construction of hope in the context of HIV/AIDS in South Africa. the theoretical framework is built from a base of cultural theory, discourse analysis and theology, and binds these together into a transdisciplinary argument.

Increased migration is one of the main challenges impacting on health system performance. The World Health Organisation (WHO) framed responsiveness, fair financing, and equity as the intrinsic goals of a health system. In line with this framework, we attempted to map existing research on migration and health system performance. A qualitative systematic review was conducted. We followed the processes indicated for evidence mapping synthesis reviews, which included choosing the scope and research topic, searching, and selecting evidence, reporting findings, and identifying the evidence. We improved the primary review by first performing a brief scoping review, which served as the analytical basis for the systematic review extraction process. Articles found during the scoping review were evaluated again during the bigger systematic review phase. We refined the study's eligibility criteria as well as the data extraction items. Seventy-two articles were considered for the review. Out of this total (55/72) were published between 2016 and 2021. Our analysis showed fairness in financing, weak governance and leadership, the absence of a universally acceptable definition of migration, limited access of migrants to healthcare, equity, health worker attitude towards migrants, dignity, and health care quality to migrants as key challenges that affect health system performance. The mapping exercise shows more literature on migration and health system performance, but also shows gaps requiring urgent attention, including integration of the health system goals in implementing health interventions. We conclude that countries are recognising the challenges of migration on health system performance. Migration is slowly being included in national health policies in low- and middle- income countries, however challenges to implementation of such policies exist. Migration is recognised as a human right and the ethical obligation of health institutions. More agenda setting and funding for bridging work on migration and health system performance is recommended.

After independence, post-Soviet countries embarked on various trajectories of health system development, some more successfully than others. Several countries throughout the region, limited by political and economic constraints, continue to struggle with health systems strengthening, leading to negative downstream effects on population health. For countries further behind in their development trajectories, learning from successful reform experiences could support health policymaking, though health policy and systems research on this topic is scarce, particularly in the former Soviet Union. To begin to address this gap, a mixed-methods historical case study was conducted, analysing and comparing two post-Soviet health system development experiences—in Estonia and Moldova. The cases were selected on the basis of specific differentiators, to capture a wider range of regional experiences. The country case studies focused analysis on four health systems areas, in accordance with the European Observatory on Health Systems and Policies' Health Systems in Transition framework—namely organisation and governance, financing, physical and human resources, and provision of services. Quantitative and qualitative data were synthesized, with quantitative data including select demographic, macroeconomic, and population health indicators, and qualitative data including thematic analysis of policy and research materials. The study utilised a combined complex adaptive systems and historical institutionalist perspective. The subsequent cross-country comparative analysis sought to identify ‘good health at low cost' practices appropriate to a post-Soviet context, with the aim of drawing lessons towards health systems strengthening in the broader region. Study findings suggest that political commitment to the health system development project is key; specific policies around revenue collection and pooling mechanisms are important; privatisation should be applied strategically; a holistic strategy around service provision is necessary, balancing hospital, primary health care, and public health reform; engaging external organisations in terms of financial and technical assistance can be advantageous; and health worker supply issues must be addressed. Given the contextual dissimilarities between the two country case studies, overlapping reform trends are likely indicative of regional specificities. Such knowledge can be leveraged to benefit other post-Soviet states, towards optimal health system development along the post-Soviet historical pathway.

Dignity, as a basic human right, is demonstrated across numerous leading human rights declarations, covenants, conventions and is reflected in many national constitutions globally. The World Health Organization, along with corresponding United Nations agencies, have also regularly identified dignity as a guiding principle for health systems, service provision, and reform, as dignity is commonly used to measure or achieve quality, person-centred, respectful, and responsive health systems. The prioritization of dignity is argued to improve health outcomes, strengthen professional dignity, and contribute to stronger, more responsive, and rights-based health systems. Yet despite these perceived benefits and the pervasiveness of dignity as a core issue and right, there is a surprising lack of evidence documenting what role dignity has in a health system, for example, whether it influences systems functioning or performance. To address this gap, a qualitative systematic review was conducted in two parts, starting with an initial global scoping review of evidence on dignity in health systems, followed by a systematic review to identify facilitators and barriers to supporting dignity in sub- Saharan African health systems according to the three levels of the health system: interpersonal (micro), organizational (meso), and system-wide (macro). This study found facilitators and barriers to dignity are prominent and present within the health system; and that facilitators and barriers can mainly be viewed as manifestations of prevailing socio-political and health system contexts which shape organizational hardware and software and influence interpersonal engagements between health system actors. For example, national contexts of health care worker shortages and strikes resulted in inadequate staffing levels at facilities, which attributed to decreased supervision, deviations from standards of care, strained professional dignity, and influenced organizational culture normalizing verbal abuse against patients. These contexts ultimately shaped rushed and hostile interactions between a patient and healthcare workers and consequently acted as a barrier to both patient and professional dignity in the health system. Like any system, barriers and facilitators to dignity were closely related to each other and were observed at all levels of the health system. Policy, discrimination, resource availability, organizational culture, staffing and professional dignity, and accountability were re-occurring, and interconnecting factors described as facilitators of and barriers to dignity in SSA health systems. While enabling international guidelines and human-rights declarations, health policy, private, nongovernmental, primary health care (PHC) facilities, birth companions, training, and health care worker resiliency were identified as supportive factors to dignity in health systems, overwhelmingly challenges associated with pervasive discrimination, organizational culture, and structural inadequacies described at health facilities acted as an unequivocal barrier to both patient and professional dignity in sub-Saharan African health systems. This systematic review study confirms that dignity is a critically important issue to health systems and health policy and systems research – but that it is still poorly conceptualized, theorized, or evidenced in relation to how it influences systems functioning and performance.

Maternal vaccination has been widely recognised as a key component of the comprehensive package of antenatal care aimed at improving maternal and child health. Low- and middle-income countries (LMICs) are currently falling short of maternal and neonatal mortality targets, with gaps in quality health coverage and a high burden of vaccine-preventable diseases that affect both maternal and child health (MCH). There is a variety and increase of grey and published literature in recent years from LMICs on maternal vaccination programmes and their importance in addressing these gaps in MCH. However, there is a gap in the available literature for research on the role of health systems in the functioning of maternal vaccination programmes, particularly in LMICs. Based on available evidence, understanding health systems determinants of maternal vaccine uptake and delivery requires qualitative insight to inform maternal vaccine programming. A qualitative systematic review was conducted in two phases: a rapid scoping review exploring maternal vaccination and health systems was followed by a systematic review to identify health systems determinants of maternal vaccine delivery and uptake in LMICs. The systematic review was conducted following the Preferred Reporting Items for Systematic Review and Meta-analyses guidelines. Six electronic databases were searched for primary research from LMICs published in English between 2009 and 2021. A qualitative approach to data extraction and evidence synthesis was guided by conceptual health systems framing developed through the scoping review. Thematic analysis identified key descriptive and analytical themes to explore the health systems barriers and enablers of maternal vaccine delivery and uptake in LMICs. Of the 1 242 records identified through database searches, 47 studies were included in the systematic review from 28 LMICs. The majority of included studies were from the South America region (28/47) and included pregnant women as the primary population study group (38/47). Included literature explored mainly Influenza (25/47) and Tetanus toxoid (18/47) maternal vaccine uptake and delivery. Health systems enablers of maternal vaccine uptake included high level of maternal trust in healthcare providers and policy-makers. Barriers to uptake include out-of-pocket spending for vaccination services. Poor communication of policy and guidelines between policy-makers and public/private healthcare providers was identified as a barrier to vaccine delivery, in addition to reliance on external donor funding for vaccine programme implementation and reliance on paper-based antenatal and vaccination records. Urban residence and shorter travelling times to facilities enabled vaccine uptake during pregnancy, while influence of family and influential community members serves as a barrier to vaccine uptake. Limited healthcare worker capacity and subsequent decreased time spent educating patients is a barrier to both vaccine uptake and delivery for pregnant women. Health systems determinants of maternal vaccine delivery and uptake identified and explored in this review study highlight the need for improved communication of vaccine policy guidelines and safety between healthcare providers, policy-makers, pregnant women and the broader community. Monitoring and reporting systems for vaccine delivery in MCH need to be strengthened to inform service delivery policies. This review study provides a health systems approach to maternal vaccination and contributes to the increasing body of work in MCH that can inform future introduction of new maternal vaccines in LMICs.

Since the Alma Ata Declaration of 1978, community participation in health policy development and health system functioning has called for a collaborative intersectoral approach, engaging civil society as a pivotal agent for improving policy-makers' responsiveness in the public health system. Intersectoral approaches are widely accepted and research has shown the value in engaging communities in the improvement of their health. However, astonishingly little is known about the overall configuration, nature, and focus of the ‘spaces' where civil society are participating in health system-relevant engagement, or their contribution towards improved system responsiveness. This study describes a local provincial health system, the Western Cape province in South Africa, mapping the intersectoral spaces where civil society participates in the health system, provides feedback to the system (towards responsiveness), and contributes to health system improvement decisions. A mixed method case study was conducted, integrating desk-based review of multiple forms of openly available data, with verification from experts in the field. Sixteen intersectoral spaces in the Western Cape health system were mapped and compared, with analysis focussing on current governance practices in these spaces, evidence of accountability measures and civil society participation within the broader goal of improving health system responsiveness. Multiple spaces exist for intersectoral engagement in the Western Cape of South Africa, but there is a lack of any ‘system-wide' integrative approach – which creates overlap, a focus on vertical programming, and parts of civil society remain ‘disconnected' from the system. Feedback from civil society back into national or provincial policy-making processes is sporadic due to fragmented tiered governance. New efforts towards ‘whole-system' intersectoral collaboration need to be initiated and actively protected, if they are to succeed. This study demonstrates that while ‘intersectoral action for responsiveness strengthening' is broadly encouraged in this health system, it needs to be more fully assessed and operationalised in terms of multilevel governance, accountability and civil society empowerment. In doing so avenues can be identified for improving civil society's feedback into the public health system, and ensuring adequate system's response to this feedback, in health policy and practice.

International non-governmental organisations (INGOs) play a critical role in improving the capacity of health systems to deliver services in sub-Saharan Africa (SSA), especially in fragile and conflict affected states (FCAS). Nonetheless, the sustainability of public private engagement (PPE) initiatives between health systems and INGOs is threatened by various factors including, decline in developmental and humanitarian assistance and a shift in policies and priorities. Consequently, many INGOs are exiting PPE initiatives. There is a lack of evidence about the process of withdrawal of INGOs from low- and middle-income countries and FCAS settings, in particular, how the nature of the withdrawal (beyond the basic loss of funds) affects the functioning of the health system, especially at lower levels of primary care. This mini dissertation presents a research protocol (Section A), and a journal formatted manuscript (Section B) for a case study of the impact of withdrawal of INGOs from public health facilities in Tsholotsho district, Matabeleland North Province, Zimbabwe. This study describes the process of withdrawal by three INGOs from PPE initiatives with Tsholotsho District Hospital (TDH). Understanding this process better and learning how public health facilities cope with the withdrawal of partner support, provides lessons on how to efficiently sustain the gains from PPE initiatives. In these three cases, PPEs were ended because of an ending of funds. Despite the existence of exit and sustainability plans, in all cases, the withdrawal process was fraught and difficult to navigate. There was a discrepancy between plans and what transpired during and after funding-withdrawal. The common issues that affected exit implementation included abruptness of the withdrawal by INGOs; lack of resources to sustain the intervention after withdrawal of funding; and design, depth and scope of intervention. In addition, lack of clear regulatory mechanisms that shape PPE initiatives and govern the withdrawal of partners from public facilities also affected the process. Due to these factors, the interventions either stopped or continued at a drastically reduced scale. Withdrawal of partners, especially in FCAS, has dire implications for the health system, and need to be managed with much greater attention given to (unintended) consequences to the health system and its resilience. Health system assessments and analytics should be performed by expert independent parties prior to the ending of PPEs, which would enable context-specific withdrawal plans that might aid in mitigating future difficulties.

Media is a crucial factor in shaping public opinion and setting policy agendas. There is limited research on the role of media in health policy processes in low- and middle-income countries. This study profiles South Africa as a case example, currently in the process of implementing a major health policy reform, National Health Insurance (NHI). A descriptive, mixed methods study was conducted in five phases. Evidence was gathered through a scoping review of secondary literature; discourse analysis of global policy documents on universal health coverage and South African NHI policy documents; and a content and discourse analysis of South African print and online media texts focused on NHI. Representations in the media were analysed and dominant discourses that might influence the policy process were identified. Dominant discourses in SA media were identified relating to ‘health as a global public good', biopolitics, and corruption. Media representations focused on political contestation and the impact of NHI on elite actors. Representations in the media did not acknowledge the lived reality of most of the South African population. The discourses identified might influence the policy process by reinforcing socially dominant discourses and power structures, and hindering public participation. This might reinforce current inequalities in the health system, with negative repercussions for access to health care. This study highlights the need to understand mainstream media as part of a people centred health system, particularly in the context of universal health coverage reforms such as NHI. This would require the formation of collaborative and sustainable networks of policy actors, including actors within media, to develop strategies to counter-act harmful representations in the media that might reinforce inequalities and prevent successful implementation of NHI. Strategies should also investigate how to leverage media within health policy processes to decrease inequalities and increase access to health care. Research should be undertaken to explore media in other diverse formats and languages, and in other contexts, particularly low- and middle-income countries, to further understand media's role in health policy processes.

Community participation is an effective strategy for strengthening health systems and progressively realising health rights. For meaningful community participation to occur, the capacity of formal or informal community organisations and mechanisms involved in addressing social determinants of health needs to be strengthened. One way of doing this is through training. There is minimal research on the efforts of community structures set up to address social determinants of health and health needs in communities, following training to strengthen their capacity. This study sought to evaluate the successes and challenges of a particular Community Systems Strengthening Project which, between 2016 and 2019, set out to train health committee members and community health activists in Gugulethu, South Africa. In so doing, it investigated whether and how the health committee members and Community Health Activists assumed an activist role in the community and are engaging in meaningful community participation. A mixed methods evaluative study was conducted in two phases during 2020-2021. The first phase was a scoping review of available literature, followed by an evaluative study including review of project documents, observation by attending events organised by the project and other community organisations, and in-depth interviews with health committee members (2), community health activists (4) and project staff (4). The training intervention was found to have influenced the health committee members and Community Health Activists thinking, understanding and practice in their community efforts to address social determinants of health. Therefore, adequate support, training, and an enabling environment can facilitate meaningful community participation in health. Ultimately, these measures will contribute to the progressive realisation of the right to health and the right to community participation, and ultimately health system transformation. The limited adaptability of the intervention, limited resources, participant perceptions and sustainability were found to be obstacles to meaningful community participation. This dissertation consists of two parts. The study protocol, Part A, outlines the rationale of undertaking this research and the proposed methods. Part B consists of the journal ready manuscript which presents the results and discussion of the research findings.

Faith-based mental health provision as a model of mental health service delivery is not widely acknowledged or researched, despite being highly utilised, especially in the African context. There is currently limited empirical research or review work on the various types of faith-based health providers which contribute mental health services, the magnitude of these services, or their quality. This mixed-methods systematic review study looked at these aspects of faith-based mental health provision in the African context. In the first phase of this study, we conducted a scoping review with a wider, which resulted in a typology of models of faith-based mental health provision The typology included five different types of faith-based health individual and organisational providers (herbalists, traditional and faith healers, Christian and Muslim clergy, faith-based organisations, and chaplains). In the second phase of the study, we conducted a systematic review based on the typology in which we assessed these models of FBHP against service type and level (facility or community, individual or organisational providers); medical provision type (biomedical or alternative). There were 53 studies included in this systematic review and the findings suggest that there is a wide array of types of faith-based providers providing a variety of mental health services across Africa. The research question formulated for the purposes of the systematic review aim to address the types, magnitude and quality of faith-based mental health services in Africa. For the purposes of this review, magnitude was categorised as including frequency of utilisation and availability of faith-based mental health services, but the information was limited. In addition, there are red flags regarding the quality of these mental health services which include human rights abuses that were discussed in this review. This exploratory review demonstrates some of the challenges in dealing with the complex variety of 'religious entities' in Africa. To some degree, developing conclusions that are applicable to all faith-based mental health providing entities is counterproductive - and instead a main conclusion is that future research and engagement needs to take this variety into account. There are a few common trends - for example challenges facing most faith-based providers in relation to faith-based provision of mental health services is financial support for mental health services. Regarding both traditional/alternative and biomedical mental health services, it has been noted that, there is a need to consider cost to the patient (e.g., reduce out of pocket payments). In addition, the literature suggests that better training for some types of faith-based health providers is urgently needed, especially those working close to community. Community mental health education interventions could strengthen faith-based provision of mental healthcare, and prevent some human rights abuses (religious perils), and improve the quality of faith-based mental health service provision. Better referral systems and improved communication between faith-based health providers and biomedical practitioners is required. In addition, varied types of faith-based health providers need to be included in mental health policy development and implementation. Finally, the most comprehensive conclusion of this exploratory review, is that further research is needed on specific types of faith-based providers engaged in mental health service provision, and further research is needed on the integration of mental health services in African health systems.

Despite national governments striving for responsive health systems and the implementation of mechanisms and interventions to foster citizen feedback and participation in health, current evidence does not adequately address these mechanisms and interventions in low-income and middle-income countries (LMICs). This mixed method descriptive and exploratory study ‘maps' types of health system responsiveness mechanisms and their functionality in the South African health system, with a focus on the Western Cape Province, based on the available descriptive evidence. Multiple forms of data are scrutinized and synthesized to provide a deeper, contextual understanding of ´formal´ mechanisms that are constituted or mandated into South African and Western Cape policies and guidelines. This research shows that while national, provincial and district policies make strong provisions for health system responsiveness, including mechanisms to foster citizen feedback, in reality, implementation is not standardised and sometimes non-functional. Many of these mechanisms also currently exist in isolation, failing to feed into an overarching strategy of health system responsiveness, where feedback mechanisms may complement one another and lead to quality improvement in the health system. While there are cases for effective and well-functioning mechanisms for receiving and responding to citizen feedback, government on all levels is often hampered by resources and other constraints. These findings have implications for health researchers as well as national and provincial policymakers, seeking to enhance health system functioning.

There is a significant amount of public health research conducted within provincial health facilities in South Africa, whose findings have a positive impact on the delivery of health services. This includes clinical, epidemiological, health systems and health services research, often initiated by post‐graduate students, independent academics researchers, as well as research institutions. Although researchers commonly commit to providing feedback to the provincial department and facilities, there is little evidence to confirm that research feedback is subsequently provided. Little contextualized empirical evidence is available to guide action, particularly for frontline health care providers, who often have the responsibility to host these research activities. The aim of this study was to explore the experiences of healthcare providers with research activities hosted in health facilitiesin the Western Cape province of South Africa. A mixed-method, cross-sectional study was conducted utilising an online survey (n= 19), and semi-structured interviews (n=3) with frontline health care providers (research gatekeepers). Descriptive analyses characterized respondents and their experience of research. Qualitative thematic analysis took on an inductive approach by identifying themes as they emerged from the data and cross comparing these with findings from the scoping literature review. Findings provided insight into how research conduct is experienced by those on the frontline in public health facilities on the provincial district platform. This is particular to the Western Cape province, which has a specific health department administration system. The following themes emerged: perception of research burden on services, understanding of the research approval process, autonomy to deny researchers access to the health facility due to overburden of research, the frequency or occurrence of research feedback after completion of a project, and interpersonal dynamics between researchers and gatekeepers as it relates to research conduct in facilities. This research reports on empirical evidence of perspectives from frontline health care providers on their experience with health research in a particular provincial context. The findings could form the basis of a study with a much larger sample size to inform how research feedback can be translated in a way that directly impacts on the uptake in the frontline.

Like most health interventions, National Immunization Programs (NIPs) are embedded within health systems. This means that NIPs and health systems exist in a constant interaction. Vaccine preventable diseases are widely recognized as the chief cause of morbidity, disability and mortality worldwide and NIPs are understood to be one of the most cost-effective interventions against this burden. In low and middle- income countries (LMICs), where the burden of disease is high, NIPs have been reported to perform at suboptimal levels. It has been suggested that this suboptimal performance of NIPs can be associated with the poor state of health systems in LMIC. Despite this, the interaction between NIPs and health systems is poorly understood. In addition to this, systematic evidence on how health systems constraints and facilitators impact on the performance of NIPs in LMICs is scarce. To address this evidence gap, a systematic review study was conducted, that involved an initial scoping review of the evidence-base on NIPs and health systems in LMICs from which a logic model was developed. This logic model was then applied as a guide for a qualitative systematic review aimed at assessing the health systems constraints and facilitators of NIP performance in sub-Saharan Africa. The findings of this review suggest that well-performing NIPs are those that operate within enabling health systems, characterized by the availability of strong political endorsement for vaccines, clear governance structures and effective collaboration with global partners. Despite this, significant health systems constraints persist and include the limited capacity of health workers in sub-Saharan Africa, weak country infrastructure, poor service delivery, inadequate vaccine communication and ineffective community engagement in immunization programs. This systematic review study contributes to our limited understanding of the interaction between NIPs and health systems. In addition, the findings show how system-wide constraints and facilitators impact on the performance of NIPs. These findings have relevance for ongoing health systems strengthening initiatives, especially where NIPs are concerned.

Within the context of health system strengthening and pharmaceutical systems development goals, a population must have equitable access to quality affordable medicines and pharmaceutical supplies. The utilization of the private (for-profit and not-for-profit) pharmaceutical sector actors by the public to promote universal access to quality medicines and related commodities is an increasingly common practice in resource poor settings. Faith-based drug supply organizations (FB-DSOs), as a component of the private-not-for-profit (PNFP) sector, are increasingly involved in the supply of pharmaceuticals to complement public sector efforts in wider coverage of communities in Africa. However, their role in the pharmaceutical system in Africa is not well defined. This paper presents the results of a systematic review conducted to map out the organization of pharmaceutical systems and establish the role of faith-based health care providers in the pharmaceutical supply chain in Africa. For this study, a scoping review was first conducted to map the literature on pharmaceutical supply chains in low- and middle-income countries (LMICs), understand the challenges facing pharmaceutical supply chainsin LMICs and the role faith-based health care providers play in the pharmaceutical supply chain. After this, a qualitative systematic review was conducted across multiple electronic databases to identify documents that contain information on faith-based involvement in pharmaceutical supply chain in Africa. Citation tracking was used to identify further relevant articles. Included materials were analyzed using thematic narrative analysis and synthesized. The public pharmaceutical supply chain in Africa is faced with challenges including drug stock outs and irregular supplies, shortage of trained pharmacy personnel and lack of system for drug regulation and quality assurance. Faith-based health care providers involved in pharmaceutical supply chain do exist extensively as drug supply organizations or as a Christian Health Association with a pharmaceutical supply chain. They have been in existence in Africa for a very long time now contributing to the national pharmaceutical system in Africa. The review revealed that faith-based involvement in pharmaceutical chains tended to improve access to the general population and inserted additional pharmaceutical supplies into the national pharmaceutical system - which tended to strengthen the broader public private partnership between faith-based health providers and the public sector. This analysis confirmed that African pharmaceutical supply systems continue to face challenges. There is a major evidence gap relating to PNFP contribution to pharmaceutical systems - as is evidenced by this study on faith-based contributions to African pharmaceutical systems (which can be understood as a tracer for a broader concern). There is a particular lack of evidence about the national supply chain, and how faith-based PNFP engagement contribute or detract from the national pharmaceuticalsupply chain. FB-DSOs complement the public pharmaceutical system by improving access to medicines and related commodities in Africa.

Weakening health systems in the Middle East and North Africa (MENA) region has led to a shift towards a greater acknowledgement of the involvement of non-state providers in health care services and delivery. A wide range of non-state health providers exist in the region, one type being Islamic health providers (IHPs) which fall under the category of non-state, not-for profit health providers. There is very little information available about the non-state sector in the MENA region, and almost nothing about IHPs, although anecdotally they are described as providers of choice, said to provide high quality services at low cost. This research aims to explore the public/private mix in the MENA region, delving into the types of collaborations that occur between the public and non-state sector. It will then narrow down in a single case study focusing on looking at IHPs in on MENA country (Egypt), and consider how IHPs 'fit’ within their national health system. Egypt was chosen for this study as IHPs have a long presence there, as Egypt is the birthplace of many Islamic groups such as the Muslim Brotherhood, which then migrated to neighboring countries. Common themes found in the case study was the lack of regulations for both the non-state sector and IHPs, competition in service provision with the public sector, and inequality in provision of health services (the latter issue observed in the broader non-state sector in the MENA region, but not specifically in IHPs). With regards to IHPs in Egypt, they were found to serve nearly 20% of the population. Exact numbers of the presence of IHPs in the country is difficult to obtain, as they are largely invisible in literature and are often categorized as non-governmental organizations (NGOs). Estimates show that there are around 5000 NGOs providing primary health care (PHC) and other health services. Most of these facilities are concentrated in urban areas. It was found that the 'Islamic’ label of IHPs is utilised either to gain donations, to denote the fact that this is a charitable institution, or because the facility is attached to a mosque. Most of the IHPs in the country practice a form of social rather than political Islam, making them not that different from other non-state secular facilities.

Aims: Empirical research has proven that a strong primary health care (PHC) system produces better health outcomes and therefore, PHC is an important part of a country's health system. This systematic review focuses on the intended aims and targets of PHC reforms conducted in Finland from 1993 onwards. It describes the challenges that the Finnish PHC system has faced, comparing the objectives and the problem with other similar countries, providing lessons from the Finnish experiences for other countries. Methods: A Campbell-styled systematic review was conducted. Databases including Ebsco, Pubmed/MEDLINE, Scopus, Google Scholar and a Finnish health science database Medic were searched. The keywords and MeSH Terms for the review included terms relating to 'health systems', 'primary care', 'reform', and 'Finland' (see Appendix B). English terms were used when using Medline, Scopus and EBSCO, and both Finnish and English terms were used when using Medic. Reference lists of included papers were also searched. Data was extracted and analysed by utilising thematic analysis. Results: 13 relevant papers were found that dealt with PHC policies or reforms implemented in Finland between 1993 and 2015. The aims of the reforms were classified under five themes, which were developed based on a prior scoping review and then tested during data extraction. The themes were: efficient governance and financing, adequate and equitable access, improved quality, increased patient choice and cooperation and integration of services. Conclusions: A number of policies and reforms have been implemented which have directly or indirectly aimed to strengthen the Finnish PHC system. Some policies have intended to strengthen PHC overall while others have focused on only one aspect or challenge. There has recently been a strong tendency to re-centralise health services, and the importance of patient choice and service integration have become increasingly important. Integration and cooperation of different service providers is one of the newest solutions when finding ways to strengthen weak PHC systems. This study shows that in policy success context matters. PHC strengthening needs to be high on the political agenda, and enough resources are needed. This study showed that there have been few durable or sustainable solutions, and further research is needed especially from the overall health systems perspective.

Faith-based health providers (FBHPs) have been identified as important actors and allies in health service delivery, especially in weak and fragile health systems in sub-Saharan Africa (SSA). Although FBHPs are still present in a number of SSA countries in varying degrees and capacities, in South Africa FBHPs were nationalized in the 1970s with some of these missionary facilities later being entirely closed. This historical case study draws on primary and secondary archival data collection as well as in-depth interviews, and discusses the reasoning and some of the results of nationalizing FBHPs in South Africa. We find that FBHPs were nationalized for financial and political reasons in the Apartheid era with the effects of the decision still being felt in the late 1990s. This has resulted in the shifting of efforts of some faith communities from health service delivery to more ‘health-related development programming’ such as orphanages, old age homes, step-down primary clinics and ‘faith inspired organizations’ that promote health through the provision of food, water and shelter. The story of the nationalization of FBHPs into the South African health system is important, especially for other countries still pondering the presence of these types of faith health providers in their national health systems’ architecture.