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Health Research Policy and Systems. 2018 May 22; 16(1):42.BACKGROUND: As countries continue to improve their family planning (FP) programmes, they may draw on WHO's evidence-based FP guidance and tools (i.e. materials) that support the provision of quality FP services. METHODS: To better understand the use and perceived impact of the materials and ways to strengthen their use by countries, we conducted qualitative interviews with WHO regional advisors, and with stakeholders in Ethiopia and Senegal who use WHO materials. RESULTS: WHO uses a multi-faceted strategy to directly and indirectly disseminate materials to country-level decision-makers. The materials are used to develop national family planning guidelines, protocols and training curricula. Participants reported that they trust the WHO materials because they are evidence based, and that they adapt materials to the country context (e.g. remove content on methods not available in the country). The main barrier to the use of national materials is resource constraints. CONCLUSIONS: Although the system and processes for dissemination work, improvements might contribute to increased use of the materials. For example, providers may benefit from additional guidance on how to counsel women with characteristics or medical conditions where contraceptive method eligibility criteria do not clearly rule in or rule out a method.
The relative roles of ANC and EPI in the continuous distribution of LLINs: a qualitative study in four countries.
Health Policy and Planning. 2017 May 1; 32(4):467-475.Background: The continuous distribution of long-lasting insecticidal nets (LLINs) for malaria prevention, through the antenatal care (ANC) and the Expanded Programme on Immunizations (EPI), is recommended by the WHO to improve and maintain LLIN coverage. Despite these recommendations, little is known about the relative strengths and weaknesses of the ANC and EPI-based LLIN distribution. This study aimed to explore and compare the roles of the ANC and EPI for LLIN distribution in four African countries. Methods: In a qualitative evaluation of continuous distribution through the ANC and EPI, semi-structured, individual and group interviews were conducted in Kenya, Malawi, Mali, and Rwanda. Respondents included national, sub-national, and facility-level health staff, and were selected to capture a range of roles related to malaria, ANC and EPI programmes. Policies, guidelines, and data collection tools were reviewed as a means of triangulation to assess the structure of LLIN distribution, and the methods of data collection and reporting for malaria, ANC and EPI programmes. Results: In the four countries visited, distribution of LLINs was more effectively integrated through ANC than through EPI because of a) stronger linkages and involvement between malaria and reproductive health programmes, as compared to malaria and EPI, and b) more complete programme monitoring for ANC-based distribution, compared to EPI-based distribution. Conclusions: Opportunities for improving the distribution of LLINs through these channels exist, especially in the case of EPI. For both ANC and EPI, integrated distribution of LLINs has the potential to act as an incentive, improving the already strong coverage of both these essential services. The collection and reporting of data on LLINs distributed through the ANC and EPI can provide insight into the performance of LLIN distribution within these programmes. Greater attention to data collection and use, by both the global malaria community, and the integrated programmes, can improve this distribution channel strength and effectiveness.
Providing Family Planning Services at Primary Care Organizations after the Exclusion of Planned Parenthood from Publicly Funded Programs in Texas: Early Qualitative Evidence.
Health Services Research. 2017 Oct 20;OBJECTIVE: To explore organizations' experiences providing family planning during the first year of an expanded primary care program in Texas. DATA SOURCES: Between November 2014 and February 2015, in-depth interviews were conducted with program administrators at 30 organizations: 7 women's health organizations, 13 established primary care contractors (e.g., community health centers, public health departments), and 10 new primary care contractors. STUDY DESIGN: Interviews addressed organizational capacities to expand family planning and integrate services with primary care. DATA EXTRACTION: Interview transcripts were analyzed using a theme-based approach. Themes were compared across the three types of organizations. PRINCIPAL FINDINGS: Established and new primary care contractors identified several challenges expanding family planning services, which were uncommon among women's health organizations. Clinicians often lacked training to provide intrauterine devices and contraceptive implants. Organizations often recruited existing clients into family planning services, rather than expanding their patient base, and new contractors found family planning difficult to integrate because of clients' other health needs. Primary care contractors frequently described contraceptive provision protocols that were not evidence-based. CONCLUSIONS: Many primary care organizations in Texas initially lacked the capacity to provide evidence-based family planning services that women's health organizations already provided. (c) Health Research and Educational Trust.
A number of factors explain why WHO guideline developers make strong recommendations inconsistent with GRADE guidance.
Journal of Clinical Epidemiology. 2016; 70:111-122.Objective: Many strong recommendations issued by the World Health Organization (WHO) are based on low- or very low-quality (low certainty) evidence (discordant recommendations). Many such discordant recommendations are inconsistent with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance. We sought to understand why WHO makes discordant recommendations inconsistent with GRADE guidance. Study Design and Setting: We interviewed panel members involved in guidelines approved by WHO (2007e2012) that included discordant recommendations. Interviews, recorded and transcribed, focused on use of GRADE including the reasoning underlying, and factors contributing to, discordant recommendations. Results: Four themes emerged: strengths of GRADE, challenges and barriers to GRADE, strategies to improve GRADE application, and explanations for discordant recommendations. Reasons for discordant recommendations included skepticism about the value of making conditional recommendations; political considerations; high certainty in benefits (sometimes warranted, sometimes not) despite assessing evidence as low certainty; and concerns that conditional recommendations will be ignored. Conclusion: WHO panelists make discordant recommendations inconsistent with GRADE guidance for reasons that include limitations in their understanding of GRADE. Ensuring optimal application of GRADE at WHO and elsewhere likely requires selecting panelists who have a commitment to GRADE principles, additional training of panelists, and formal processes to maximize adherence to GRADE principles. Copyright: 2016 Elsevier Inc.
Influences on participant reporting in the World Health Organisation drugs exposure pregnancy registry; a qualitative study.
BMC Health Services Research. 2014; 14:525.BACKGROUND: The World Health Organisation has designed a pregnancy registry to investigate the effect of maternal drug use on pregnancy outcomes in resource-limited settings. In this sentinel surveillance system, detailed health and drug use data are prospectively collected from the first antenatal clinic visit until delivery. Over and above other clinical records, the registry relies on accurate participant reports about the drugs they use. Qualitative methods were incorporated into a pilot registry study during 2010 and 2011 to examine barriers to women reporting these drugs and other exposures at antenatal clinics, and how they might be overcome. METHODS: Twenty-seven focus group discussions were conducted in Ghana, Kenya and Uganda with a total of 208 women either enrolled in the registry or from its source communities. A question guide was designed to uncover the types of exposure data under- or inaccurately reported at antenatal clinics, the underlying reasons, and how women prefer to be asked questions. Transcripts were analysed thematically. RESULTS: Women said it was important for them to report everything they had used during pregnancy. However, they expressed reservations about revealing their consumption of traditional, over-the-counter medicines and alcohol to antenatal staff because of anticipated negative reactions. Some enrolled participants' improved relationship with registry staff facilitated information sharing and the registry tools helped overcome problems with recall and naming of medicines. Decisions about where women sought care, which influenced medicines used and antenatal clinic attendance, were influenced by pressure within and outside of the formal healthcare system to conform to conflicting behaviours. Conversations also reflected women's responsibilities for producing a healthy baby. CONCLUSIONS: Women in this study commonly take traditional medicines in pregnancy, and to a lesser extent over-the-counter medicines and alcohol. The World Health Organisation pregnancy registry shows potential to enhance their reporting of these substances at the antenatal clinic. However, more work is needed to find optimal techniques for eliciting accurate reports, especially where the detail of constituents may never be known. It will also be important to find ways of sustaining such drug exposure surveillance systems in busy antenatal clinics.
Suboptimal patterns of provider initiated HIV testing and counselling, antiretroviral therapy eligibility assessment and referral in primary health clinic attendees in Blantyre, Malawi.
Tropical Medicine and International Health. 2012 Apr; 17(4):507-17.OBJECTIVE: To understand reasons for suboptimal and delayed uptake of antiretroviral therapy (ART) by describing the patterns of HIV testing and counselling (HTC) and outcomes of ART eligibility assessments in primary clinic attendees. METHODS: All clinic attendances and episodes of HTC were recorded at two clinics in Blantyre. A cohort of newly diagnosed HIV-positive adults (>15 years) was recruited and exit interviews undertaken. Logistic regression models were constructed to investigate factors associated with referral to start ART. Qualitative interviews were conducted with providers and patients. RESULTS: There were 2398 episodes of HTC during 18,021 clinic attendances (13.3%) between January and April 2011. The proportion of clinic attendees undergoing HTC was lowest in non-pregnant women (6.3%) and men (8.5%), compared with pregnant women (47.2%). Men had more advanced HIV infection than women (79.7% WHO stage 3 or 4 vs. 56.4%). Problems with WHO staging and access to CD4 counts affected ART eligibility assessments; only 48% completed ART eligibility assessment, and 54% of those reporting WHO stage 3/4 illnesses were not referred to start ART promptly. On multivariate analysis, HIV-positive pregnant women were significantly less likely to be referred directly for ART initiation (adjusted OR: 0.29, 95% CI: 0.13-0.63). CONCLUSIONS: These data show that provider-initiated testing and counselling (PITC) has not yet been fully implemented at primary care clinics. Suboptimal ART eligibility assessments and referral (reflecting the difficulties of WHO staging in primary care) mean that simplified eligibility assessment tools are required to reduce unnecessary delay and attrition in the pre-ART period. Simplified initiation criteria for pregnant women, as being introduced in Malawi, should improve linkage to ART. (c) 2012 Blackwell Publishing Ltd.
[Organizational change: the implementation of children-friendly hospitals] Mudanca organizacional: implantacao da Iniciativa Hospital Amigo da Crianca.
Ciencia and Saude Coletiva. 2010 Jun; 15 Suppl 1:1263-73.Empirical evidences have pointed out the relevant role of breastfeeding to diminish infantile mortality. Children-friendly Hospitals (IHAC) is a worldwide action developed by the United Nations Children's Fund - UNICEF and by the World Health Organization, aiming to promote, protect and support breastfeeding and also prevent precocious weaning. The aim of the present study is to identify the main organizational changes which occurred in two hospitals, located in the State of Minas Gerais, Brazil that implemented IHAC. The organizational analysis carried out was based upon six perspectives, according to Motta's analytical chart that includes: strategic, structural, cultural, human, technological and political perspectives. A qualitative research was carried out, by using as a data gathering method the semi-structured interview, applied in all hierarchical levels. In order to interpret data, it was adopted the content analysis. In both cases, it could be concluded that the implementation of IHAC resulted in changes and improvement in the management of the organizations, due to the establishment of procedural patterns and staff training. It was verified that the cultural and technological changes occurred in a more intense manner and that the least perceived were the political and strategic changes.
Strong ministries for strong health systems. An overview of the study report: Supporting Ministerial Health Leadership: A Strategy for Health Systems Strengthening.
[Kampala], Uganda, African Centre for Global Health and Social Transformation [ACHEST], 2010 Jan.  p.This overview is adapted from the report Supporting Ministerial Health Leadership: A Strategy for Health Systems Strengthening by Dr. Francis Omaswa, executive director and founder of The African Center for Global Health and Social Transformation (ACHEST) and Dr. Jo Ivey Boufford, president of The New York Academy of Medicine (NYAM). The study and report were commissioned by the Rockefeller Foundation to explore the feasibility of establishing a support mechanism for ministers and ministries of health especially in the poorest countries, as part of the Foundation’s Transforming Health Systems initiative, The study was initially designed to assess the potential value of three proposed programs to strengthen the leadership capabilities of ministers of health: a global executive leadership program for new ministers; an ongoing, regional, in-person and virtual leadership support program for sitting ministers; and a virtual global resource center for ministers and high level ministerial officials providing real-time access to information. During the course of the study, it became clear that it was essential to expand the inquiry to better understand the challenges and needs of ministries as a whole, as they and their ministers provide the stewardship function for country health systems.The content of the report was derived from six major activities:a comprehensive literature review of the theory and practice of effective leadership development and organizational capacity building, and an environmental scan to identify any existing or planned leadership development programs for ministers of health or any that have occurred in the recent past globally; a survey of the turnover of ministers of health; targeted interviews with ministers, former ministers, and key stakeholders who interact with them, conducted between October 2008 and September 2009, to better understand the roles of ministers and ministries, the challenges they face, resources at their disposal, and their thoughts on what additional resources might enhance their personal effectiveness and that of their ministries; a consultative meeting of experts and stakeholders held in Bellagio, Italy part way through the project; participation of the project leaders (Omaswa and Boufford) in relevant global and regional meetings, as well as individual meetings about the project with critical leaders in international and donor organizations and potential champions of this effort; and a consultation with African regional health leaders to discuss the final report, held in Kampala, Uganda. (Excerpt).
Coordination, management and utilization of foreign assistance for HIV / AIDS prevention in Vietnam. Assessment report.
Ha Noi, Vietnam, CCRD, 2006 Oct. 82 p. (CCRD Assesssment Report)International assistance for HIV / AIDS prevention and control in Vietnam has significantly contributed to combating this epidemic. However, while current resources have not yet fully met the needs, the management and utilization of resources still had many limitations which affect the effectiveness of foreign assistance and investments. The independent assessment was prepared for the Conference on “the Coordination of Foreign Assistance for HIV / AIDS Prevention and Control”. Analytical assessment and comments on the management and coordination of foreign aid were made on the basis of Government’s official procedures and regulations on those issues. This research was carried out in October, 2006.
Population and Environment. 2007 Sep; 29(1):12-24.This paper conceptualizes the absence of multilateral protection for environmental refugees. It does this by critically scrutinizing interviews conducted with United Nations ambassadors and senior diplomats in 2004 (n = 45) in a number of key policy-making locations. These interviews reveal that an absence of policy on environmental refugees has been reproduced by discursive politics at the United Nations. The reasons for which are explored here in this paper, and include shifting attitudes towards the role of multilateralism and environmental issues generally. (author's)
[Unpublished] 2004. Presented at the Conference on Gender Justice in Post-Conflict Situations, "Peace Needs Women and Women Need Justice”. Co-organized by the United Nations Development Fund for Women [UNIFEM] and the International Legal Assistance Consortium. New York, New York, September 15-17, 2004. 4 p.Unfortunately, this is extremely well documented in countries in conflict. Many of the reports submitted to the Security Council include mention of the use of rape as a weapon of war. Recently, a report of the United Nations Organization Mission in the Democratic Republic of the Congo (MONUC) on the situation of human rights in Ituri provided information on this problem which is as specific as it is frightening. But, paradoxically, in countries which are not in conflict, the issue of violence against women is often neglected, where it is not concealed. But the private sphere cannot be an area where rights do not apply. (excerpt)
Paris, France, UNESCO, 2006. 71 p. (Policy Paper Poverty Series No. 14.1 (E); SHS/CCT/2006/PI/H/3)Trafficking in human beings, especially women and girls, is not new. Historically, it has taken many forms, but in the context of globalization, has acquired shocking new dimensions. It is a complex, multi-faceted phenomenon involving multiple stakeholders at the institutional and commercial level. It is a demand-driven global business with a huge market for cheap labour and commercial sex confronting often insufficient or unexercised policy frameworks and trained personnel to prevent it. Mozambique is but one of an estimated 10 African countries (Angola, Botswana, DRC, Lesotho, Malawi, Mozambique, Swaziland, Tanzania, Zambia and Zimbabwe) that fuel the human trafficking business that feeds South Africa, the regional magnet. The recent history of armed conflict, extremes of dislocation and loss, reconstruction, political upheaval and deep social scars, together with its particular geography and the AIDS pandemic make Mozambique an inviting target for organized crime. The impact of these events on women and children, together with systemic gender discrimination and the absence of protective legislation make them particularly exposed to human trafficking. (excerpt)
Paris, France, UNESCO, 2006. 70 p. (Policy Paper Poverty Series No. 14.2 (E); SHS/CCT/2006/PI/H/2)Trafficking in human beings, especially women and girls, is not new. Historically it has taken many forms, but in the context of globalization, has acquired shocking new dimensions. It is a complex, multi-faceted phenomenon involving multiple stakeholders at the institutional and commercial level. It is a demand-driven global business with a huge market for cheap labour and commercial sex confronting often insufficient or unexercised policy frameworks or trained personnel to prevent it. Nigeria has acquired a reputation for being one of the leading African countries in human trafficking with cross-border and internal trafficking. Trafficking of persons is the third largest crime after economic fraud and the drug trade. Decades of military regimes in Nigeria have led to the institutionalized violation of human rights and severe political, social and economic crises. This negatively impacts the development of community participation, especially of women and children, despite international institutions designed to advance their causes. In addition, the oil boom in the 1970s created opportunities for migration both inside and outside of the country. This created avenues for exploitation, for international trafficking in women and children, for forced labor and for prostitution. (excerpt)
New York, New York, United Nations Population Fund [UNFPA], . 70 p.Achieving gender equality and equity through the empowerment of women is a crucial strategic goal of the United Nations Population Fund (UNFPA). As population and development thinking has evolved to include a sound understanding of gender, so, too, have the UNFPA mandate, policies, programmes and organizational structure. Numerous publications and training materials produced by UNFPA organizational units have aimed at facilitating an understanding of gender-related concepts. Yet, the subject of gender remains challenging for UNFPA staff. Many reviews and evaluations mention the need for more clarity and practical guidance on gender mainstreaming (see glossary) in programming. This assessment set out to help meet that need. Its objectives were as follows: To assess the quality, packaging and design of gender-related messages being communicated to UNFPA staff; To assess the utility and utilization of these materials by interviewing stakeholders in UNFPA headquarters and the field; To identify good practices to improve the communication of gender concepts and their mainstreaming into all UNFPA materials; and To promote a common understanding of what should be done at the organizational level to institutionalize strengths and achievements in current practice. (excerpt)
Women, peace and security. Study submitted by the Secretary-General pursuant to Security Council resolution 1325 (2000).
New York, New York, United Nations, 2002.  p.On 31 October 2000, the Security Council adopted resolution 1325 (2000) on women, peace and security, which builds on the Presidential Statement of 8 March 2000 and a series of Council resolutions on children and armed conflict, the protection of civilians in armed conflict and the prevention of armed conflict. On 24 and 25 October 2000, the Security Council held an open discussion on women, peace and security, in which 40 Member States made statements supporting the mainstreaming of gender perspectives into peace support operations and the participation of women in all aspects of peace processes. The discussion followed an Arria Formula meeting 3 on women, peace and security on 23 October 2000 that afforded an opportunity for the members of the Council to discuss the impact of armed conflict on women, and the role of women in peace processes, with women representatives of non -governmental organizations (NGOs) from Guatemala, Sierra Leone, Somalia and Zambia. They presented the experiences of women and girls in armed conflict and also raised the concerns of grass-roots movements of women committed to preventing and solving conflicts, and bringing peace, security and sustainable development to their communities. (excerpt)
AIDS Education and Prevention. 2003 Aug; 15(4):346-356.In the past decade, the resettlement of African HIV-positive refugees in New Zealand has meant dramatically changing patterns of new HIV infection. This increase in heterosexually acquired HIV has been met by mounting disquiet on the part of the public, politicians, and health officials. The voices of the refugees themselves have been lost in this debate. This article discusses the experiences of African refugees with HIV, being in New Zealand, and the establishment of the National HIV/AIDS Refugee Health Education Program, designed to meet the needs of African communities in New Zealand. (author's)
[Project-generated organizational learning: El-Haouz province and Essaouira province cases] L'Apprentissage organisationnel généré par les projets: "cas des provinces d'El Haouz et d'Essaouira".
[Rabat], Maroc, Institut National d'Administration Sanitaire [INAS], 2002 Jul. , 64,  pMoroccan healthcare structures, both at the central and peripheral levels have traditional organization and management centered on a certain fragmentation in management and vertical integration of programs and healthcare activities. It is for this reason that Morocco maintains cooperative relationships with several countries or international bodies in all domains, including that of health, for purposes of exchanging with them and benefiting from their technical and financial assistance via projects likely to improve the health of the population. Of course, each project results in learning in terms of mastering the technical tools of management by health professionals. It is in this sense that this study from the INAS (National Institute for Health Administration) was undertaken. The goal is to evaluate organizational learning generated in the context of projects initiated in the El Haouz and Essaouira provinces, and to determine its conditions, obstacles, and limits. This study should be taken as qualitative evaluative research, based on a questionnaire given to delegates of the provinces that were the study sites and to members of the local team involved in project management who had responsibilities in this area; on a focus group, and on semi-directed interviews with provincial managers. Analysis of the results led to the following syntheses: The mode of management by project offers the opportunity for health professionals to improve their abilities. But they should make an effort to adapt to conditions in the field, and show that they are committed in this process; the domain of organizational learning should revolve around three components: technical, behavioral, and managerial, provided the last is better integrated since it seems to lag behind the other two. Also, the ability to learn in the context of projects is certainly conditioned by a certain number of factors that must be considered to better master the constraints and work for the implementation of favorable conditions for organizational learning. At the end of this work, recommendations were made in order to enhance and improve the quality of implementing the project management mode in sanitary structures across which develops organizational learning for the purpose of better meeting the needs of the population and strengthening capacities in health professionals.
Agrobiodiversity strategies to combat food insecurity and HIV / AIDS impact in rural Africa. Advancing grassroots responses for nutrition, health and sustainable livelihoods. Preliminary edition.
Rome, Italy, Food and Agriculture Organization of the United Nations [FAO], 2003.  p.This strategy paper has been developed in the framework of the FAO Population and Development Service (SDWP), under the support and lead of Marcela Villarreal (SDWP Chief). The paper aims at stimulating grassroots action for household food, nutrition and livelihood security in rural Africa, placing special emphasis on the evolving needs owing to the HIV/AIDS crisis. For the elaboration of the proposed strategies, the author carried out a specific FAO field mission to Uganda and Tanzania, as well as supplementary fieldwork in Ethiopia and Mali, in September-December 2001. (author's)
ORS is never enough: physician rationales for altering standard treatment guidelines when managing childhood diarrhoea in Thailand.
Social Science and Medicine. 2003 Sep; 57(6):1031-1044.This study explores Thai physicians’ rationales about their prescribing practices for treating childhood diarrhoea within the public hospital system in central Thailand. Presented first are findings of a prospective clinical audit and observations of 424 cases treated by38 physicians used to estimate the prevalence of sub-optimal prescribing practices according to Thai government and WHO treatment guidelines. Second, qualitative interview data are used to identify individual, inter-personal, socio-cultural and organisational factors influencing physicians’ case management practices. Importantly, we illustrate how physicians negotiate between competing priorities, such as perceived pressure by caretakers to over-prescribe for their child and the requirement of health authorities that physicians in the public health system act as health resource gatekeepers. The rationales offered by Thai physicians for adhering or not adhering to standard treatment guidelines for childhood diarrhoea are contextualised in the light of current clinical, ethical and philosophical debates about evidence-based guidelines. We argue that differing views about clinical autonomy, definitions of optimal care and optimal efficiency, and tensions between patient-oriented and community-wide health objectives determine how standard practice guidelines for childhood diarrhoea in Thailand are implemented. (author's)
Journal of Community Psychology. 1999 Jul; 27(4):393-404.In many Third World countries there is a large population of street children. The causes of this phenomenon are diverse; for example, rapid urbanization, worsening economic trends, and rampant population growth. This study reveals the range of difficulties that plague projects for street children in Nairobi, Kenya. The data were collected by means of semi-structured interviews. In total, seven projects were visited and 68 street children were interviewed. Recommendations to improve assistance to and care of street children in Nairobi are presented. (author's)
Fees-for-services, cost recovery, and equity in a district of Burkina Faso operating the Bamako Initiative. [Prestation de services, couverture des coûts et équité dans une région au Burkina-Faso exploitant l'Initiative de Bamako]
Bulletin of the World Health Organization. 2003 Jul; 81(7):532-538.Objective: To gauge the effects of operating the Bamako Initiative in Kongoussi district, Burkina Faso. Methods: Qualitative and quasi-experimental quantitative methodologies were used. Findings: Following the introduction of fees-for-services in July 1997, the number of consultations for curative care fell over a period of three years by an average of 15.4% at ‘‘case’’ health centres but increased by 30.5% at ‘‘control’’ health centres. Moreover, although the operational results for essential drugs depots were not known, expenditure increased on average 2.7 times more than income and did not keep pace with the decline in the utilization of services. Persons in charge of the management committees had difficulties in releasing funds to ensure access to care for the poor. Conclusion: The introduction of fees-for-services had an adverse effect on service utilization. The study district is in a position to bear the financial cost of taking care of the poor and the community is able to identify such people. Incentivesmust be introduced by the state and be swiftly applied so that the communities agree to a more equitable system and thereby allow access to care for those excluded from services because they are unable to pay. (author's)