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Background: Systemic lupus erythematosus (SLE) is a life-threatening, chronic, autoimmune disease requiring long term subspecialty care due to its complex and chronic nature. Childhood-onset SLE (cSLE) is more severe than adult-onset, and the cSLE population in South Africa has been reported to have an even higher risk than patients elsewhere. Therefore, it is critical to promptly diagnose, treat, and manage cSLE. In this paper, we aim to describe and evaluate barriers and enablers of appropriate long-term care of cSLE South Africa from the perspective of caregivers (parents or family members). Methods: Caregivers (n = 22) were recruited through pediatric and adult rheumatology clinics. Individuals were eligible if they cared for youth (≤ 19 years) who were diagnosed with cSLE and satisfied at least four of the eleven ACR SLE classification criteria. Individual in-depth, semi-structured interviews were conducted between January 2014 and December 2014, and explored barriers to and facilitators of ongoing chronic care for cSLE. Data were analyzed using applied thematic analysis. Results: Four barriers to chronic care engagement and retention were identified: knowledge gap, financial burdens, social stigma of SLE, and complexity of the South African medical system. Additionally, we found three facilitators: patient and caregiver education, robust support system for the caregiver, and financial support for the caregiver and patient. Conclusion: These findings highlight multiple, intersecting barriers to routine longitudinal care for cSLE in South Africa and suggest there might be a group of diagnosed children who don't receive follow-up care and are subject to loss to follow-up. cSLE requires ongoing treatment and care; thus, the different barriers may interact and compound over time with each follow-up visit. South African cSLE patients are at high risk for poor outcomes. South African care teams should work to overcome these barriers and place attention on the facilitators to improve care retention for these patients and create a model for other less resourced settings. [ABSTRACT FROM AUTHOR]

Background: Older persons report poor health status and greater need for healthcare. However, there is limited research on older persons' healthcare disparities in Uganda. Therefore, this paper aimed at investigating factors associated with older persons' healthcare access in Uganda, using a nationally representative sample. Methods: We conducted secondary analysis of data from a sample of 1602 older persons who reported being sick in the last 30 days preceding the Uganda National Household Survey. We used frequency distributions for descriptive data analysis and chi-square tests to identify initial associations. We fit generalized linear models (GLM) with the poisson family and the log link function, to obtain incidence risk ratios (RR) of accessing healthcare in the last 30 days, by older persons in Uganda. Results: More than three quarters (76%) of the older persons accessed healthcare in the last 30 days. Access to healthcare in the last 30 days was reduced for older persons from poor households (RR = 0.91, 95% CI: 0.83-0.99); with some walking difficulty (RR = 0.90, 95% CI: 0.83-0.97); or with a lot of walking difficulty (RR = 0.84, 95% CI: 0.75-0.95). Conversely, accessing healthcare in the last 30 days for older persons increased for those who earned wages (RR = 1.08, 95% CI: 1.00-1.15) and missed work due to illness for 1-7 days (RR =1.19, 95% CI: 1.10-1.30); and 8-14 days (RR = 1.19, 95% CI: 1.07-1.31). In addition, those who reported non-communicable diseases (NCDs) such as heart disease, hypertension or diabetes (RR= 1.09, 95% CI: 1.01-1.16); were more likely to access healthcare during the last 30 days. Conclusion: In the Ugandan context, health need factors (self-reported NCDs, severity of illness and mobility imitations) and enabling factors (household wealth status and earning wages in particular) were the most important determinants of accessing healthcare in the last 30 days among older persons. [ABSTRACT FROM AUTHOR]

Background: There is an increasing recognition that non communicable diseases impose large economic costs on households, societies and nations. However, not much is known about the magnitude of diabetes expenditure in African countries and to the best of our knowledge no systematic assessment of the literature on diabetes costs in Africa has been conducted. The aim of this paper is to capture the evidence on the cost of diabetes in Africa, review the methods used to calculate costs and identify areas for future research.Methods: A desk search was conducted in Pubmed, Medline, Embase, and Science direct as well as through other databases, namely Google Scholar. The following eligibility criteria were used: peer reviewed English articles published between 2006 and 2016, articles that reported original research findings on the cost of illness in diabetes, and studies that covered at least one African country. Information was extracted using two data extraction sheets and results organized in tables. Costs presented in the studies under review are converted to 2015 international dollars prices (I$).Results: Twenty six articles are included in this review. Annual national direct costs of diabetes differed between countries and ranged from I$3.5 billion to I$4.5 billion per annum. Indirect costs per patient were generally higher than the direct costs per patient of diabetes. Outpatient costs varied by study design, data source, perspective and healthcare cost categories included in the total costs calculation. The most commonly included healthcare items were drug costs, followed by diagnostic costs, medical supply or disposable costs and consultation costs. In studies that reported both drug costs and total costs, drug costs took a significant portion of the total costs per patient. The highest burden due to the costs associated with diabetes was reported in individuals within the low income group.Conclusion: Estimation of the costs associated with diabetes is crucial to make progress towards meeting the targets laid out in Sustainable Development Goal 3 set for 2030. The studies included in this review show that the presence of diabetes leads to elevated costs of treatment which further increase in the presence of complications. The cost of drugs generally contributed the most to total direct costs of treatment. Various methods are used in the estimation of diabetes healthcare costs and the costs estimated between countries differ significantly. There is room to improve transparency and make the methodologies used standard in order to allow for cost comparisons across studies. [ABSTRACT FROM AUTHOR]

Background: Transgender and gender diverse (TGD) people face significant challenges in accessing timely, culturally competent, and adequate healthcare due to structural and systemic barriers, yet there is a lack of research exploring the access and utilization of healthcare services within African TGD communities. To address this gap, this systematic review explored: (1) barriers to accessing healthcare services and gender-affirming hormone therapy (GAHT) faced by TGD people, (2) demographic and societal factors correlated with the utilization of healthcare services and GAHT, (3) common healthcare and support services utilized by TGD people, and (4) patterns of accessing healthcare services and GAHT within TGD communities. Methods: A systematic literature search was conducted in PubMed, Embase, and Scopus in September 2023. Eligible studies included peer-reviewed original research, reports, and summaries published in the English language assessing health service accessibility and utilization of TGD people in Africa between January 2016 and December 2023. Results: From 2072 potentially relevant articles, 159 were assessed for eligibility following duplicate removal, and 49 were included for analysis. Forty-five articles addressed barriers to accessing healthcare services and GAHT, seven focused on demographic and societal factors correlated with the utilization of healthcare services and GAHT, 16 covered common healthcare and support services utilized by TGD people, and seven examined patterns of accessing healthcare services and GAHT. Findings suggested a limited availability of health services, inadequate knowledge of TGD healthcare needs among healthcare providers, a lack of recognition of TGD people in healthcare settings, healthcare-related stigma, and financial constraints within African TGD communities. An absence of studies conducted in Northern and Central Africa was identified. Conclusions: TGD people in Africa encounter significant barriers when seeking healthcare services, leading to disparity in the utilization of healthcare and resulting in a disproportionate burden of health risks. The implications of these barriers highlight the urgent need for more high-quality evidence to promote health equity for African TGD people. Trial registration: PROSPERO CRD42024532405. [ABSTRACT FROM AUTHOR]

Background: The recent introduction of Direct Acting Antivirals (DAAs) for treating Hepatitis C Virus (HCV) can significantly assist in the world reaching the international target of elimination by 2030. Yet, the challenge facing many individuals and countries today lies with their ability to access these treatments due to their relatively high prices. Gilead Sciences applies differential pricing and licensing strategies arguing that this provides fairer and more equitable access to these life-saving medicines. This paper analyses the implications of Gilead's tiered pricing and voluntary licencing strategy for access to the DAAs.Methods: We examined seven countries in Africa (Egypt, Ethiopia, Nigeria, Democratic Republic of Congo, Cameroon, Rwanda and South Africa) to assess their financial capacity to provide DAAs for the treatment of HCV under present voluntary licensing and tiered-pricing arrangements. These countries have been selected to explore the experience of countries with a range of different burdens of HCV and shared eligibility for supply by licensed generic producers or from discounted Gilead prices.Results: The cost of 12-weeks of generic DAA varies from $684 per patient treated in Egypt to $750 per patient treated in other countries. These countries can also procure the same DAA for 12-weeks of treatment from the originator, Gilead, at a cost of $1200 per patient. The current prices of DAAs (both from generic and originator manufacturers) are much more than the median annual income per capita and the annual health budget of most of these countries. If governments alone were to bear the costs of universal treatment coverage, then the required additional health expenditure from present rates would range from a 4% increase in South Africa to a staggering 403% in Cameroon.Conclusion: The current arrangements for increasing access to DAAs, towards elimination of HCV, are facing challenges that would require increases in expenditure that are either too burdensome to governments or potentially so to individuals and families. Countries need to implement the flexibilities in the Doha Declaration on Trade Related Intellectual Property Rights agreement, including compulsory licensing and patent opposition. This also requires political commitment, financial will, global solidarity and civil society activism. [ABSTRACT FROM AUTHOR]

Introduction: The COVID-19 pandemic unveiled huge challenges in health workforce governance in the context of public health emergencies in Africa. Several countries applied several measures to ensure access to qualified and skilled health workers to respond to the pandemic and provide essential health services. However, there has been limited documentation of these measures. This study was undertaken to examine the health workforce governance strategies applied by 15 countries in the World Health Organization (WHO) Africa Region in responding to the COVID-19 pandemic. Methods: We extracted data from country case studies developed from national policy documents, reports and grey literature obtained from the Ministries of Health and other service delivery agencies. This study was conducted from October 2020 to January 2021 in 15 countries - Angola, Burkina Faso, Chad, Eswatini, Ghana, Guinea, Guinea Bissau, Ivory Coast, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal and Togo. Results: All 15 countries had national multi-sectoral bodies to manage the COVID-19 response and a costed national COVID-19 response plan. All the countries also reflected human resources for health (HRH) activities along the different response pillars. These activities included training for health workers, and budget for the recruitment or mobilization of additional health workers to support the response, and for provision of financial and non-financial incentives for health workers. Nine countries recruited additional 35,812 health workers either on a permanent or temporary basis to respond to the COVID-19 with an abridged process of recruitment implemented to ensure needed health workers are in place on time. Six countries redeployed 3671 health workers to respond to the COVID-19. The redeployment of existing health workers was reported to have impacted negatively on essential health service provision. Conclusion: Strengthening multi-sector engagement in the development of public health emergency plans is critical as this promotes the development of holistic interventions needed to improve health workforce availability, retention, incentivization, and coordination. It also ensures optimized utilization based on competencies, especially for the existing health workers. [ABSTRACT FROM AUTHOR]

Background: Because of the shortage of health professionals, particularly in specialty areas, Rwanda initiated the Human Resources for Health (HRH) Program. In this program, faculty from United States teaching institutions (USF) "twin" with Rwandan Faculty (RF) to transfer skills. This paper assesses the twinning model, exploring USF and RF goal setting, satisfaction and perceptions of the effectiveness of skill transfer within the twinning model.Methods: All USF and RF in the HRH Program from August 2012-May 2014 were invited to participate. An 85-item questionnaire for USF and 71-item questionnaire for RF were administered via Survey Monkey in April and May 2014. Associations among primary outcomes were assessed and factors related with outcomes were modeled using logistic regression.Results: Most RF and USF reported setting goals with their twin (89% and 71%, respectively). Half of RF (52%) reported effective skill transfer compared to 10% of USF. Only 38% of RF and 28% of USF reported being very satisfied with the twinning model. There was significant overlap in the three operational outcomes. For RF, the following factors were associated with outcomes: for effective skill transfer, being able to communicate in a common language and working at a nursing site outside of Kigali; and for satisfaction, 7+ years of professional experience and being part of a male RF-female USF twin pair. For USF, the following factors were associated with outcomes: for setting goals, prior teaching experience; and for satisfaction, experience in low resource settings for one month or less and feeling that HRH promotes a culture of respect.Conclusions: Twinning is the cornerstone of the HRH Program in Rwanda. These findings helped the HRH team identify key areas to improve the twinning experience including better recruitment and orientation of USF and RF, consideration of additional factors during the twinning process, provide language training support, facilitate joint twin activities and cross-cultural training and improve the site leadership buy-in and support of the program. These results can inform other programs using twinning to develop skills in the health workforce. [ABSTRACT FROM AUTHOR]

Background: In spite of the investments made by the Ugandan Government, the utilisation of maternal health services has remained low, resulting in a high maternal mortality (438 maternal deaths per 100,000 live births). Aiming to reduce poor women's constraints to the utilisation of services, an intervention consisting of a voucher scheme and health system strengthening was implemented. This paper presents the lessons learnt during the setup and implementation of the intervention in Eastern Uganda, in order to inform the design and scale up of similar future interventions.Methods: The key lessons were synthesised from a variety of project reports, as well as qualitative data drawn from six focus group discussions and four in-depth interviews conducted in the Buyende and Pallisa districts during the implementation phase of the voucher scheme.Results and Conclusions: To promote the successful implementation of interventions with demand and supply side initiatives, such as voucher schemes, the health system should be able to respond to the demand created by providing the additional required resources such as health workers, essential supplies and equipment. Involving a diverse, multi-sectoral group of stakeholders is important for addressing the different barriers experienced by women when seeking maternal health services. Voucher schemes should have a mechanism of detecting unintended consequences and mitigating them. Sustainability plans should be built into such interventions to maintain the gains achieved. Lastly, health policy planners can use this information to develop follow-up programmes to test modified versions that are more sustainable. Such programmes could use locally existing community structures for management and resource mobilisation for self-sustainment. [ABSTRACT FROM AUTHOR]

Background: Globally, countries are taking actions to ensure that their population have improved access to people-centred and integrated health services. Attaining this requires improved access to health workers at all levels of health service delivery and equitably distributed by geographical location. Due to the persistent health worker shortages, countries have resorted to implementing task shifting and task sharing in various settings to optimally utilize existing health workers to improve access to health services. There are deliberations on the need for an implementation framework to guide the adoption and operationalization of task shifting and task sharing as a key strategy for optimally utilizing the existing health workforce towards the achievement of UHC. The objective of this study was to develop an implementation framework for task shifting and task sharing for policy and practice in Africa. Methods: A sequential multimethod research design supported by scoping reviews, and qualitative descriptive study was employed in this study. The evidence generated was synthesized into an implementation framework that was evaluated for applicability in Africa by 36 subject matter experts. Results: The implementation framework for task shifting and task sharing has three core components – context, implementation strategies and intended change. The implementation strategies comprise of iterative actions in the development, translation, and sustainment phases that to achieve an intended change. The implementation strategies in the framework include mapping and engagement of stakeholders, generating evidence, development, implementation and review of a road map (or action plan) and national and/or sub-national policies and strategies, education of health workers using manuals, job aids, curriculum and clinical guidelines, and monitoring, evaluation, reviews and learning. Conclusion: The implementation framework for task shifting and task sharing in Africa serves as a guide on actions needed to achieve national, regional and global goals based on contextual evidence. The framework illustrates the rationale and the role of a combination of factors (enablers and barriers) in influencing the implementation of task shifting and task sharing in Africa. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has the potential to cause high morbidity and mortality in crisis-affected populations. Delivering COVID-19 treatment services in crisis settings will likely entail complex trade-offs between offering services of clinical benefit and minimising risks of nosocomial infection, while allocating resources appropriately and safeguarding other essential services. This paper outlines considerations for humanitarian actors planning COVID-19 treatment services where vaccination is not yet widely available. We suggest key decision-making considerations: allocation of resources to COVID-19 treatment services and the design of clinical services should be based on community preferences, likely opportunity costs, and a clearly articulated package of care across different health system levels. Moreover, appropriate service planning requires information on the expected COVID-19 burden and the resilience of the health system. We explore COVID-19 treatment service options at the patient level (diagnosis, management, location and level of treatment) and measures to reduce nosocomial transmission (cohorting patients, protecting healthcare workers). Lastly, we propose key indicators for monitoring COVID-19 health services. [ABSTRACT FROM AUTHOR]

Background: The increasing burden of non-communicable diseases (NCDs) in sub-Saharan Africa is causing further burden to the health care systems that are least equipped to deal with the challenge. Countries are developing policies to address major NCD risk factors including tobacco use, unhealthy diets, harmful alcohol consumption and physical inactivity. This paper describes NCD prevention policy development process in five African countries (Kenya, South Africa, Cameroon, Nigeria, Malawi), including the extent to which WHO "best buy" interventions for NCD prevention have been implemented.Methods: The study applied a multiple case study design, with each country as a separate case study. Data were collected through document reviews and key informant interviews with national-level decision-makers in various sectors. Data were coded and analyzed thematically, guided by Walt and Gilson policy analysis framework that examines the context, content, processes and actors in policy development.Results: Country-level policy process has been relatively slow and uneven. Policy process for tobacco has moved faster, especially in South Africa but was delayed in others. Alcohol policy process has been slow in Nigeria and Malawi. Existing tobacco and alcohol policies address the WHO "best buy" interventions to some extent. Food-security and nutrition policies exist in almost all the countries, but the "best buy" interventions for unhealthy diet have not received adequate attention in all countries except South Africa. Physical activity policies are not well developed in any study countries. All have recently developed NCD strategic plans consistent with WHO global NCD Action Plan but these policies have not been adequately implemented due to inadequate political commitment, inadequate resources and technical capacity as well as industry influence.Conclusion: NCD prevention policy process in many African countries has been influenced both by global and local factors. Countries have the will to develop NCD prevention policies but they face implementation gaps and need enhanced country-level commitment to support policy NCD prevention policy development for all risk factors and establish mechanisms to attain better policy outcomes while considering other local contextual factors that may influence policy implementation such as political support, resource allocation and availability of local data for monitoring impacts. [ABSTRACT FROM AUTHOR]

Background: If there is one universal recommendation to countries wanting to make progress towards Universal Health Coverage (UHC), it is to develop the learning capacities that will enable them to 'find their own way' - this is especially true for countries struggling with fragmented health financing systems. This paper explores results from a multi-country study whose main aim was to assess the extent to which UHC systems and processes at country level operate as 'learning systems'.Method: This study is part of a multi-year action-research project implemented by two communities of practice active in Africa. For this specific investigation, we adapted the concept of the learning organisation to so-called 'UHC systems'. Our framework organises the assessment around 92 questions divided into blocks, sub-blocks and levels of learning, with a seven scale score in a standardised questionnaire developed during a protocol and methodology workshop attended by all the research teams. The study was implemented in six francophone African countries by national research teams involving researchers and cadres of the ministries involved in the UHC policy. Across the six countries, the questionnaire was administrated to 239 UHC actors. Data were analysed per country, per blocks and sub-blocks, by levels of learning and per question.Results: The study confirms the feasibility and relevance of adapting the learning organisation framework to UHC systems. All countries scored between 4 and 5 for all the sub-blocks of the learning system. The study and the validation workshops organised in the six countries indicate that the tool is particularly powerful to assess weaknesses within a specific country. However, some remarkable patterns also emerge from the cross-country analysis. Our respondents recognise the leadership developed at governmental level for UHC, but they also report some major weaknesses in the UHC system, especially the absence of a learning agenda and the limited use of data.Conclusion: Countries will not progress towards UHC without strong learning systems. Our tool has allowed us to document the situation in six countries, create some awareness at country level and initiate a participatory action-oriented process. [ABSTRACT FROM AUTHOR]

Background: Mistreatment of women during facility-based childbirth is a major violation of human rights and often deters women from attending skilled birth. In Ethiopia, mistreatment occurs in up to 49.4% of mothers giving birth in health facilities. This study describes the development, implementation and results of interventions to improve respectful maternity care. As part of a national initiative to reduce maternal and perinatal mortality in Ethiopia, we developed respectful maternity care training module with three core components: testimonial videos developed from key themes identified by staff as experiences of mothers, skills-building sessions on communication and onsite coaching. Respectful maternity care training was conducted in February 2017 in three districts within three regions.Methods: Facility level solutions applied to enhance the experience of care were documented. Safe Childbirth Checklist data measuring privacy and birth companion offered during labor and childbirth were collected over 27 months from 17 health centers and three hospitals. Interrupted time series and regression analysis were conducted to assess significance of improvement using secondary routinely collected programmatic data.Results: Significant improvement in the percentage of births with two elements of respectful maternal care-privacy and birth companionship offered- was noted in one district (with short and long-term regression coefficient of 18 and 27% respectively), while in the other two districts, results were mixed. The short-term regression coefficient in one of the districts was 26% which was not sustained in the long-term while in the other district the long-term coefficient was 77%. Testimonial videos helped providers to see their care from their clients' perspectives, while quality improvement training and coaching helped them reflect on potential root causes for this type of treatment and develop effective solutions. This includes organizing tour to the birthing ward and allowing cultural celebrations.Conclusion: This study demonstrated effective way of improving respectful maternity care. Use of a multipronged approach, where the respectful maternity care intervention was embedded in quality improvement approach helped in enhancing respectful maternity care in a comprehensive manner. [ABSTRACT FROM AUTHOR]

Background: Homelessness is a growing concern as it affects a large number of people worldwide. Individuals and families experiencing homelessness are vulnerable in terms of health and underutilise health services. Despite being a global problem, not much is known about the range and breath of literature exploring health problems and health care service utilisation among homeless adults in Africa.Objectives: To identify the nature and scope of existing evidence on physical and mental health, and health service utilisation among homeless adults in Africa. The review aimed to examine how research is conducted, identify gaps, guide future research, and make recommendations for development and implementation of policies and practices.Methods: A search of articles and reports involving six databases: Scopus, MEDLINE, CINAHL, PubMed, African Journal Online, and Google Scholar was conducted from June 2018 to February 2019. Studies published between 1980 and 2019 that examined the health problems and health service utilisation among homeless adults in Africa were considered. Manual search in reference lists and grey literature was also done to add reports. Data was extracted manually using a charting developed. A descriptive analysis and narrative synthesis were performed.Results: Of 761 records found, 14 satisfied the pre-determined inclusion and exclusion criteria. Three themes emerged from the studies: Physical health problems, mental health problems; and healthcare services utilisation. Of the 14 included studies, nine studied and reported physical health problems such as sexually transmitted infections, injuries and disabilities, respiratory and cardiac diseases. Five studies explored mental health problems such as psychotic disorders, mood disorders, self-harm and suicidal behaviour. Only five studies investigated utilisation of different types of health care services among homeless people.Conclusions: Evidence shows that homeless adults suffered from a range of physical and mental health problems, and underutilisation of health care services. However, there is lack of information on the complex interrelationship between homelessness and health, as well as differences in prevalence of health problems among the various sub-groups of homeless. There is also lack of information regarding utilisation other important healthcare services such as mental health services, alcohol and drugs services, and accident and emergency service, and future researches should address that. Also, attention should be given to intervention models for complex and effective physical and psychiatric care as well as social support to address the homeless people's health vulnerabilities. [ABSTRACT FROM AUTHOR]

Background: Volunteers play a significant role in supporting hospice and palliative care in Africa, but little is known about the types of volunteers, their motivations and roles in service delivery. Methods: Palliative care experts from 30 African countries were invited to participate in an online survey, conducted in English and French, that consisted of 58 questions on: socio-demographics, the activities, motivation and coordination of volunteers, and an appraisal of recent developments in volunteering. The questionnaire was pre-tested in Uganda. Quantitative data was analysed descriptively with SPSS v22; answers on open-ended questions were analysed using content analysis. Results: Twenty-five respondents from 21 countries replied to the questionnaire. The typical volunteer was reported to be a female aged between 30 and 50 years. Volunteer roles included, among others: direct patient assistance, providing psychosocial / spiritual support, and assisting patients' families. Respondents considered altruism, civic engagement and personal gain (for a professional career) as volunteers' most significant motivational drivers. One in two respondents noted that recruiting volunteers is easy, and cooperation with the communities was often mentioned as helpful. Trainings mostly occurred before the first assignment, with topics covering the palliative care concept, care, psychosocial support and team work. Half of respondents described recent overall volunteering developments as positive, while the other half described problems primarily with financing and motivation. Most volunteers received transportation allowances or bicycles; some received monetary compensation. Conclusions: The findings show a wide range of volunteering in palliative care. We identified volunteers as typically 30–50 years old, non-professional females, motivated by altruism, a sense of civic engagement and personal gain. Palliative care services benefit from volunteers who take on high workloads and are close to the patients. The main challenges for volunteer programmes are funding and the long-term motivation of volunteers. [ABSTRACT FROM AUTHOR]

Background: Family medicine (FM) is a relatively new discipline in sub-Saharan Africa (SSA), still struggling to find its place in the African health systems. The aim of this review was to describe the current status of FM in SSA and to map existing evidence of its strengths, weaknesses, effectiveness and impact, and to identify knowledge gaps.Methods: A scoping review was conducted by systematically searching a wide variety of databases to map the existing evidence. Articles exploring FM as a concept/philosophy, a discipline, and clinical practice in SSA, published in peer-reviewed journals from 2000 onwards and in English language, were included. Included articles were entered in a matrix and then analysed for themes. Findings were presented and validated at a Primafamed network meeting, Gauteng 2018.Results: A total of 73 articles matching the criteria were included. FM was first established in South Africa and Nigeria, followed by Ghana, several East African countries and more recently additional Southern African countries. In 2009, the Rustenburg statement of consensus described FM in SSA. Implementation of the discipline and the roles and responsibilities of family physicians (FPs) varied between and within countries depending on the needs in the health system structure and the local situation. Most FPs were deployed in district hospitals and levels of the health system, other than primary care. The positioning of FPs in SSA health systems is probably due to their scarcity and the broader mal-distribution of physicians. Strengths such as being an "all- round specialist", providing mentorship and supervision, as well as weaknesses such as unclear responsibilities and positioning in the health system were identified. Several studies showed positive perceptions of the impact of FM, although only a few health impact studies were done, with mixed results.Conclusions: FM is a developing discipline in SSA. Stronger evidence on the impact of FM on the health of populations requires a critical mass of FPs and shared clarity of their position in the health system. As FM continues to grow in SSA, we suggest improved government support so that its added value and impact on health systems in terms of health equity and universal health coverage can be meaningfully explored. [ABSTRACT FROM AUTHOR]

Background: Routine IPV screening is a controversial topic and there is no evidence to suggest that it improves the health outcomes of women. Consequently, understanding the socio-cultural dimensions, becomes essential to ensure that victims receive appropriate and local support. This study was conducted to gather the perceptions of victims of IPV on the relevance of raising the topic at health care facilities and to determine specific categories of women to target for screening by medical personnel. It also explored how the information gathered could support victims and whether medical students should be trained on issues relating to IPV. Methods: Thirty-three key informant interviews were conducted among women attending clinics from three teaching hospitals in the Lagos, Oyo and Osun States of South West Nigeria. The hospitals offer antenatal, emergency, primary care and community outreach clinics which are well-attended by women. A six-item questionnaire assessed eligibility for participation in the study and participants were then purposively sampled. Interviews were conducted using a semi-structured guide. Ethical approval and gatekeepers' permissions were obtained, and each participant signed informed consent. Data was collected between June and November 2017. The data was entered into Excel and analysed deductively to answer each objective. Results: Most (n = 24) participants stated that medical practitioners should ask all women who present to health care facilities, about their experiences of IPV. Physically, medically and socially vulnerable women, including those in relationships with men in risky occupations, were identified as needing special attention and possible follow-up. They supported the use of the information within and outside of the health care facility, depending on the need of the woman. The majority (n = 24) indicated a need to train medical students about IPV and 19 participants suggested for the topic to be curriculated. Most victims favoured the inclusion of a multidisciplinary team in teaching medical students about IPV. Conclusions: Victims of IPV were in support of initiatives to discuss the topic among some groups of female patients in health care settings. They thought it would enhance the quality of care (medical, psychological, legal and social) to victims. They identified an inter-professional team of stakeholders to include when training medical students about IPV. [ABSTRACT FROM AUTHOR]

Background: Varicella zoster virus (VZV) causes varicella and herpes zoster. These vaccine preventable diseases are common globally. Most available data on VZV epidemiology are from industrialised temperate countries and cannot be used to guide decisions on the immunization policy against VZV in Africa. This systematic review aims to review the published data on VZV morbidity and mortality in Africa.Methods: All published studies conducted in Africa from 1974 to 2015 were eligible. Eligible studies must have reported any VZV epidemiological measure (incidence, prevalence, hospitalization rate and mortality rate). For inclusion in the review, studies must have used a defined VZV case definition, be it clinical or laboratory-based.Results: Twenty articles from 13 African countries were included in the review. Most included studies were cross-sectional, conducted on hospitalized patients, and half of the studies used varying serological methods for diagnosis. VZV seroprevalence was very high among adults. Limited data on VZV seroprevalence in children showed very low seropositivity to anti-VZV antibodies. Co-morbidity with VZV was common.Conclusion: There is lack of quality data that could be used to develop VZV control programmes, including vaccination, in Africa.Trial Registration: PROSPERO 2015: CRD42015026144 . [ABSTRACT FROM AUTHOR]

Background: More than 30 countries in sub-Saharan Africa have introduced performance-based financing (PBF) in their healthcare systems. Yet, there has been little research on the process by which PBF was put on the national policy agenda in Africa. This study examines the policy process behind the introduction of PBF program in Cameroon.Methods: The research is an explanatory case study using the Kingdon multiple streams framework. We conducted a document review and 25 interviews with various types of actors involved in the policy process. We conducted thematic analysis using a hybrid deductive-inductive approach for data analysis.Results: By 2004, several reports and events had provided evidence on the state of the poor health outcomes and health financing in the country, thereby raising awareness of the situation. As a result, decision-makers identified the lack of a suitable health financing policy as an important issue that needed to be addressed. The change in the political discourse toward more accountability made room to test new mechanisms. A group of policy entrepreneurs from the World Bank, through numerous forms of influence (financial, ideational, network and knowledge-based) and building on several ongoing reforms, collaborated with senior government officials to place the PBF program on the agenda. The policy changes occurred as the result of two open policy windows (i.e. national and international), and in both instances, policy entrepreneurs were able to couple the policy streams to effect change.Conclusion: The policy agenda of PBF in Cameroon underlined the importance of a perceived crisis in the policy reform process and the advantage of building a team to carry forward the policy process. It also highlighted the role of other sources of information alongside scientific evidence (eg.: workshop and study tour), as well as the role of previous policies and experiences, in shaping or influencing respectively the way issues are framed and reformers' actions and choices. [ABSTRACT FROM AUTHOR]

Background: The increasing numbers of people with type 2 diabetes (T2D) is a global concern and especially in sub-Saharan Africa, where diabetes must compete for resources with communicable diseases. Diabetes intensifies health care utilisation and leads to an increase in medical care costs. However, In Cameroon like in most developing countries, data on the impact of diabetes on the medical health system are scarce. We aimed to analyse the use of medical services and medicines attributable to T2D care in Yaoundé, Cameroon.Methods: We conducted a cross-sectional study comparing the use of medical services and medicines on 500 people with T2D attending the diabetic outpatient units of three hospitals in Yaoundé and 500 people without diabetes matched for age, sex and residence. We performed multivariate logistic and quantile regressions to assess the effect of diabetes on the use of medical services and medicines and the presence of other chronic health problems. Models were adjusted for age, educational level, marital status, occupation and family income.Results: Overall, the rate of use of health services was found to be greater in people with T2D than those without diabetes. People with T2D had greater odds of having an outpatient visit to any clinician (OR 97.1 [95% CI: 41.6-226.2]), to be hospitalised (OR 11.9 [95% CI: 1.6-87.9]), to take at least one medicine (OR 83.1 [37.1-185.8]) compared with people without diabetes. We also observed an association between diabetes and some chronic diseases/diabetes complications including hypertension (OR 9.2 [95% CI: 5.0-16.9]), cardiovascular diseases (OR 1.9 [95% CI: 0.8-4.9]), peripheral neuropathy (OR 6.2 [95% CI: 3.4-11.2]), and erectile dysfunction (OR 5.8 [95% CI: 2.7-12.1]).Conclusions: This study showed that the presence of diabetes is associated with an increased use of health care services and medicines as well as with some chronic diseases/diabetes complications. [ABSTRACT FROM AUTHOR]

Background: Systemic Lupus Erythematosus (SLE) is a serious multisystem autoimmune disease, which is more aggressive in children and people of African descent. In South Africa, pediatric SLE (pSLE) patients are at high risk for severe disease. Similar to pSLE worldwide, South African children and adolescents with SLE require subspecialized medical care. The aim of this study is to describe the care-seeking experiences of families and examine factors that contribute to delays in the diagnosis of pSLE. Specifically, we sought to identify factors to inform interventions that support the timely referral and diagnosis of pediatric SLE patients in South Africa. Methods: In-depth, semi-structured interviews were conducted with 22 caregivers of pSLE patients recruited from two government hospitals in Cape Town, South Africa in 2014. Interviews were audio-recorded, transcribed, and analyzed for themes related to barriers to diagnosis. Results: Six themes were identified and classified as either caregiver or health system barriers to diagnosis. Caregiver barriers included lack of knowledge regarding SLE, financial difficulties, and the social stigma of SLE. Health system barriers were lack of trained staff, a complex medical system, and misdiagnosis. Conclusion: Caregivers reported missed opportunities for diagnosing pSLE in their children. Raising public awareness may improve caregiver awareness and reduce stigma of pSLE. Improving family education at diagnosis holds potential to increase patient-physician trust and mitigate fear. Education modules for primary care providers at initial point of contact with the health care system may improve recognition of early pSLE and facilitate expedited referral to a specialist. [ABSTRACT FROM AUTHOR]

Background: Primary health care (PHC) outreach teams are part of a policy of PHC re-engineering in South Africa. It attempts to move the deployment of community health workers (CHWs) from vertical programmes into an integrated generalised team-based approach to care for defined populations in municipal wards. There has little evaluation of PHC outreach teams. Managers' insights are anecdotal.Methods: This is descriptive qualitative study with focus group discussions with health district managers of Johannesburg, the largest city in South Africa. This was conducted in a sequence of three meetings with questions around implementation, human resources, and integrated PHC teamwork. There was a thematic content analysis of validated transcripts using the framework method.Results: There were two major themes: leadership-management challenges and human resource challenges. Whilst there was some positive sentiment, leadership-management challenges loomed large: poor leadership and planning with an under-resourced centralised approach, poor communications both within the service and with community, concerns with its impact on current services and resistance to change, and poor integration, both with other streams of PHC re-engineering and current district programmes. Discussion by managers on human resources was mostly on the plight of CHWs and calls for formalisation of CHWs functioning and training and nurse challenges with inappropriate planning and deployment of the team structure, with brief mention of the extended team.Conclusions: Whilst there is positive sentiment towards intent of the PHC outreach team, programme managers in Johannesburg were critical of management of the programme in their health district. Whilst the objective of PHC reform is people-centred health care, its implementation struggles with a centralising tendency amongst managers in the health service in South Africa. Managers in Johannesburg advocated for decentralisation. The implementation of PHC outreach teams is also limited by difficulties with formalisation and training of CHWs and appropriate task shifting to nurses. Change management is required to create true integrate PHC teamwork. Policy review requires addressing these issues. [ABSTRACT FROM AUTHOR]

Background: A number of Global health initiatives (GHIs) have been created to support low and middle income countries. Their support has been of different forms. The African Region has benefitted immensely from GHIs and continues to register an increase in health partnerships and initiatives. However, information on the functioning and operationalisation of GHIs in the countries is limited.Methods: This study involved two country case studies, one in Tanzania and the other one in Zambia. Data were collected using a semi-structured questionnaire. The aims were to understand and profile the GHIs supporting health development and to assess their governance and alignment with country priorities, harmonisation and alignment of their interventions and efforts, and contribution towards health systems strengthening. The respondents included senior officers from health stakeholder agencies at the national and sub-national levels. The qualitative data were analysed using thematic content analysis in MAXQDA software.Results: Health systems in both Tanzania and Zambia are decentralised. They have benefitted from GHI support in fighting the common health problems of HIV/AIDS, tuberculosis, malaria and vaccine-preventable diseases. In both countries, no GHI adequately made use of the existing Sector-wide Approach (SWAp) mechanisms but they largely operate through their unique structures and committees. GHI efforts to improve general health governance have not been matched with similar efforts from the countries. Their support to health system strengthening has not been comprehensive but has involved the selection of a few areas some of which were disease-focused. On the positive side, however, in both Tanzania and Zambia improved alignment with the countries' priorities is noted in that most of the proposals submitted to the GHIs refer to the priorities, objectives and strategies in the national health development plans and, GHIs depend on the national health information systems.Conclusion: GHIs are important funders of health in low and middle income countries. However, there is a need for the countries to take a proactive role in improving the governance, coordination and planning of the GHIs that they benefit from. This will also maximise the return on investment for the GHIs. [ABSTRACT FROM AUTHOR]

Background: The advent of global health initiatives (GHIs) has changed the landscape and architecture of health financing in low and middle income countries, particularly in Africa. Over the last decade, the African Region has realised improvements in health outcomes as a result of interventions implemented by both governments and development partners. However, alignment and harmonisation of partnerships and GHIs are still difficult in the African countries with inadequate capacity for their effective coordination.Method: Both published and grey literature was reviewed to understand the governance, priorities, harmonisation and alignment of GHIs in the African Region; to synthesise the knowledge and highlight the persistent challenges; and to identify gaps for future research.Results: GHI governance structures are often separate from those of the countries in which they operate. Their divergent funding channels and modalities may have contributed to the failure of governments to track their resources. There is also evidence that basically, earmarking and donor conditions drive funding allocations regardless of countries' priorities. Although studies cite the lack of harmonisation of GHI priorities with national strategies, evidence shows improvements in that area over time. GHIs have used several strategies and mechanisms to involve the private sector. These have widened the pool of health service policy-makers and providers to include groups such as civil society organisations (CSOs), with both positive and negative implications. GHI strategies such as co-financing by countries as a condition for support have been positive in achieving sustainability of interventions.Conclusions: GHI approaches have not changed substantially over the years but there has been evolution in terms of donor funding and conditions. GHIs still largely operate in a vertical manner, bypassing country systems; they compete for the limited human resources; they influence country policies; and they are not always harmonised with other donors. To maximise returns on GHI support, there is need to ensure that their approaches are more comprehensive as opposed to being selective; to improve GHI country level governance and alignment with countries' changing epidemiologic profiles; and to strengthen their involvement of CSOs. [ABSTRACT FROM AUTHOR]

Background: People living with HIV (PLHIV) in African countries are living longer due to the rollout of antiretroviral drug therapy programs, but they are at increasing risk of non-communicable diseases (NCDs). However, there remain many gaps in detecting and treating NCDs in African health systems, and little is known about how NCDs are being managed among PLHIV. Developing integrated chronic care models that effectively prevent and treat NCDs among PLHIV requires an understanding of the current patterns of care delivery and the major barriers and facilitators to health care. We present a systematic review protocol to synthesize studies of healthcare delivery for an important subset of NCDs, cardiovascular and metabolic diseases (CMDs), among African PLHIV. Methods/design: We plan to search electronic databases and reference lists of relevant studies published in African settings from January 2003 to the present. Studies will be considered if they address one or both of our major objectives and focus on health care for one or more of six interrelated CMDs (ischemic heart disease, stroke, heart failure, hypertension, diabetes, and hyperlipidemia) in PLHIV. Our first objective will be to estimate proportions of CMD patients along the "cascade of care"-i.e., screened, diagnosed, aware of the diagnosis, initiated on treatment, adherent to treatment, and with controlled disease. Our second objective will be to identify unique barriers and facilitators to health care faced by PLHIV in African countries. For studies deemed eligible for inclusion, we will assess study quality and risk of bias using previously published criteria. We will extract study data using standardized instruments. We will meta-analyze quantitative data at each level of the cascade of care for each CMD (first objective). We will use meta-synthesis techniques to understand and integrate qualitative data on health-related behaviors (second objective). Discussion: CMDs and other NCDs are becoming major health concerns for African PLHIV. The results of our review will inform the development of research into chronic care models that integrate care for HIV/AIDS and CMDs among PLHIV. Our findings will be highly relevant to health policymakers, administrators, and practitioners in African settings. [ABSTRACT FROM AUTHOR]

With a global target set at reducing vision loss by 25% by the year 2019, sub-Saharan Africa with an estimated 4.8 million blind persons will require human resources for eye health (HReH) that need to be available, appropriately skilled, supported, and productive. Targets for HReH are useful for planning, monitoring, and resource mobilization, but they need to be updated and informed by evidence of effectiveness and efficiency. Supporting evidence should take into consideration (1) ever-changing disease-specific issues including the epidemiology, the complexity of diagnosis and treatment, and the technology needed for diagnosis and treatment of each condition; (2) the changing demands for vision-related services of an increasingly urbanized population; and (3) interconnected health system issues that affect productivity and quality. The existing targets for HReH and some of the existing strategies such as task shifting of cataract surgery and trichiasis surgery, as well as the scope of eye care interventions for primary eye care workers, will need to be re-evaluated and re-defined against such evidence or supported by new evidence. [ABSTRACT FROM AUTHOR]

Background: African Vaccination Week (AVW) is an initiative of the Member States of the African Region aimed at promoting vaccination and ensuring equity and access to its benefits. The initiative has proven to be particularly effective in reaching populations with limited access to regular health services as well as providing an opportunity to integrate other interventions with immunization services. Methods: Using data available from the countries within the African Region, the effectiveness of AVW in creating awareness on vaccination as well as providing platform for integrated delivery of other interventions with immunization in the African Region were explored during the 2013 and 2014 campaigns of the AVW. Results: Countries that participated in the two campaigns of AVW have integrated other interventions with immunization during the AVW. The most common integrated intervention is vitamin A supplementation, followed by deworming. However, other interventions integrated, include public health educational activities, supplementation with vitamins and minerals, provision of other health services as well as introduction of new interventions. In 2013, more than 7,500,000 doses of different vaccine antigens were delivered in17 countries. Vitamin A administered to children under 5 years and women in post-partum in 13 countries with 31,500,000 tablets distributed. Polio eradication campaigns reaching young children in ten countries with 36,711,984 doses of oral polio vaccines (OPV) was the third most common intervention added onto the AVW activities. Over 21,190,000 deworming tablets were distributed to children <5 years and pregnant women in 9 countries. With respect to nutritional interventions, 6,377,222 children were screened for malnutrition in 3 countries while 3,814,680 water, sanitation and hygiene kits were distributed in 3 countries. In 2014, these results were even higher as many more countries integrated multiple interventions in the AVW. Conclusion: Integration of other interventions with immunization during AVW, in the African Region is common and has shown potentials for improving immunization coverage, as this dedicated period is used both for catch-up campaigns and periodic intensified routine immunization. While its impact may call for further examination, it is a potential platform for integrated delivery of health interventions to people with limited access to regular health service. [ABSTRACT FROM AUTHOR]

Background: The views of practitioners at the sharp end of health care provision are now recognised as a valuable source of intelligence that can inform efforts to improve patient safety in high-income countries. Yet despite growing policy emphasis on patient safety in low-income countries, little research examines the views of practitioners in these settings. We aimed to give voice to how healthcare workers in two East African hospitals identify and explain the major obstacles to ensuring the safety of patients in their care. Methods: We conducted in-depth, face to face interviews with healthcare workers in two East African hospitals. Our sample included a total of 57 hospital staff, including nurses, physicians, technicians, clinical services staff, administrative staff and hospital managers. Results: Hospital staff in low-income settings offered broadly encompassing and aspirational definitions of patient safety. They identified obstacles to patient safety across three major themes: material context, staffing issues and inter-professional working relationships. Participants distinguished between the proximal influences on patient safety that posed an immediate threat to patient care, and the distal influences that generated the contexts for such hazards. These included contexts of severe material deprivation, but also the impact of relational factors such as teamwork and professional hierarchies. Structures of authority, governance and control that were not optimally aligned with achieving patient safety were widely reported. Conclusions: As in high-income countries, the accounts of healthcare workers in low-income countries provide sophisticated and valuable insights into the challenges of patient safety. Though the impact of resource constraints and weak governance structures are particularly marked in low-income countries, the congruence between accounts of health workers in diverse settings suggest that the origins and solutions to patient safety problems are likely to be similar everywhere and are rooted in human factors, resources, culture and behaviour. While additional resources are essential to patient safety improvement in low-income settings, such resources on their own will not be sufficient to secure the changes needed. [ABSTRACT FROM AUTHOR]

Background There is a growing recognition of China?s role as a global health donor, in particular in Africa, but there have been few systematic studies of the level, destination, trends, or composition of these development finance flows or a comparison of China?s engagement as a donor with that of more traditional global health donors. Methods Using newly released data from AidData on China?s development finance activities in Africa, developed to track under reported resource flows, we identified 255 health, population, water, and sanitation (HPWS) projects from 2000?2012, which we descriptively analyze by activity sector, recipient country, project type, and planned activity. We compare China?s activities to projects from traditional donors using data from the OECD?s Development Assistance Committee (DAC) Creditor Reporting System. Results Since 2000, China increased the number of HPWS projects it supported in Africa and health has increased as a development priority for China. China?s contributions are large, ranking it among the top 10 bilateral global health donors to Africa. Over 50% of the HPWS projects target infrastructure, 40% target human resource development, and the provision of equipment and drugs is also common. Malaria is an important disease priority but HIV is not. We find little evidence that China targets health aid preferentially to natural resource rich countries. Conclusions China is an important global health donor to Africa but contrasts with traditional DAC donors through China?s focus on health system inputs and on malaria. Although better data are needed, particularly through more transparent aid data reporting across ministries and agencies, China?s approach to South-South cooperation represents an important and distinct source of financial assistance for health in Africa. [ABSTRACT FROM AUTHOR]

Background: Increasing adoption of electronic health records in hospitals provides new opportunities for patient data to support public health advances. Such learning healthcare models have generated ethical debate in high-income countries, including on the role of patient and public consent and engagement. Increasing use of electronic health records in low-middle income countries offers important potential to fast-track healthcare improvements in these settings, where a disproportionate burden of global morbidity occurs. Core ethical issues have been raised around the role and form of information sharing processes for learning healthcare systems, including individual consent and individual and public general notification processes, but little research has focused on this perspective in low-middle income countries.Methods: We conducted a qualitative study on the role of information sharing and governance processes for inpatient data re-use, using in-depth interviews with 34 health stakeholders at two public hospitals on the Kenyan coast, including health managers, providers and researchers. Data were collected between March and July 2016 and analysed using a framework approach, with Nvivo 10 software to support data management.Results: Most forms of clinical data re-use were seen as an important public health good. Individual consent and general notification processes were often argued as important, but contingent on interrelated influences of the type of data, use and secondary user. Underlying concerns were linked to issues of patient privacy and autonomy; perceived risks to trust in health systems; and fairness in how data would be used, particularly for non-public sector re-users. Support for engagement often turned on the anticipated outcomes of information-sharing processes, as building or undermining trust in healthcare systems.Conclusions: As reported in high income countries, learning healthcare systems in low-middle counties may generate a core ethical tension between supporting a public good and respecting patient autonomy and privacy, with the maintenance of public trust acting as a core requirement. While more evidence is needed on patient and public perspectives on learning healthcare activities, greater collaboration between public health and research governance systems is likely to support the development of efficient and locally responsive learning healthcare activities in LMICs. [ABSTRACT FROM AUTHOR]

Background: The use of digital technologies to improve access to health is gaining momentum in Africa. This is more pertinent with the increasing penetration of mobile phone technology and internet use, and calls for innovative strategies to support implementation of the health-related Sustainable Development Goals and Universal Health Coverage on the continent. However, the huge potential benefits of digital health to advance health services delivery in Africa is yet to be fully harnessed due to critical challenges such as proliferation of pilot projects, poor coordination, inadequate preparedness of the African health workforce for digital health, lack of interoperability and inadequate sustainable financing, among others. To discuss these challenges and propose the way forward for rapid, cost-effective and sustainable deployment of digital health in Africa, a Digital Health Hub was held in Kigali from 8th to 9th May 2018 under the umbrella of the Transform Africa Summit 2018. Methods: The hub was organized around five thematic areas which explored the status, leadership, innovations, sustainable financing of digital health and its deployment for prevention and control of Non-Communicable Diseases in Africa. It was attended by over 200 participants from Ministries of Health and Information and Communication Technology, Private Sector, Operators, International Organizations, Civil Society and Academia. Conclusions: The hub concluded that while digital health offers major opportunities for strengthening health systems towards the attainment of the Sustainable Development Goals including Universal Health Coverage in Africa, there is need to move from Donor-driven pilot projects to more sustainable and longer term nationally owned programmes to reap its benefits. This would require the use of people-centred approaches which are demand, rather than supply-driven in order to avoid fragmentation and wastage of health resources. Government leadership is also critical in ensuring the availability of an enabling environment including national digital health strategies, regulatory, coordination, sustainable financing mechanisms and building of the necessary partnerships for digital health. Recommendations: We call on the Smart Africa Secretariat, African Ministries in charge of health, information and communication technology and relevant stakeholders to ensure that the key recommendations of the hub are implemented. [ABSTRACT FROM AUTHOR]

Background: Retention of Human Resources for Health (HRH), particularly doctors at district level is a big challenge facing the decentralized health systems in poorly resourced countries. Tanzania, with 75% of its population in rural areas, has only 26% of doctors serving in rural areas. We aimed to analyze the experiences regarding the retention of doctors at district level in Tanzania from doctors' and district health managers' perspectives.Methods: A qualitative study was carried out in three districts from June to September 2013. We reviewed selected HRH documents and then conducted 15 key informant interviews with members of the District Health Management teams and medical doctors working at the district hospitals. In addition, we conducted three focus group discussions with Council Health Management Team members in the three districts. Incentive package plans, HRH establishment, and health sector development plans from the three districts were reviewed. Data analysis was performed using qualitative content analysis.Results: None of the districts in this study has the number of doctors recommended. Retention of doctors in the districts faced the following challenges: unfavourable working conditions including poor working environment, lack of assurance of career progression, and a non-uniform financial incentive system across districts; unsupportive environment in the community, characterized by: difficulty in securing houses for rent, lack of opportunities to earn extra income, lack of appreciation from the community and poor social services. Health managers across districts endeavour to retain their doctors through different retention strategies, including: career development plans, minimum financial incentive packages and avenues for private practices in the district hospitals. However, managers face constrained financial resources, with many competing priorities at district level.Conclusions: Retention of doctors at district level faces numerous challenges. Assurance of career growth, provision of uniform minimum financial incentives and ensuring availability of good social services and economic opportunities within the community are among important retention strategies. [ABSTRACT FROM AUTHOR]