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As part of an investment by the Bill & Melinda Gates Foundation to support the Government of Bihar to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) statewide, BBC Media Action implemented multiple communication tools to support front-line worker (FLW) outreach. We analyse the impacts of a package of mHealth audio messaging and paper-based job aids used by FLWs during government-sponsored village health, sanitation and nutrition days (VHSNDs) on knowledge and practices of childbearing women across the RMNCHN continuum of care. Data from two surveys collected between July and September 2016 were analysed using logistic regression to compare health-related knowledge and behaviours between women who had been exposed at VHSNDs to the mHealth GupShup Potli (GSP) audio recordings or interpersonal communication (IPC) tools versus those who were unexposed. Exposure to GSP recordings (n=2608) was associated with improved knowledge across all continuum-of-care domains, as well as improved health-related behaviours in some domains. The odds of having taken iron-folic acid (IFA) tablets were significantly higher in exposed women (OR 1.5, 95% CI 1.1 to 2.2), as was contraceptive use (OR 2.0, 95% CI 1.2 to 3.2). There were no differences in birth preparedness or complementary feeding practices between groups. Exposure to IPC paper-based tools (n=2002) was associated with a twofold increased odds of IFA consumption (OR 2.3, 95% CI 1.7 to 3.2) and contraceptive use (OR 1.8, 95% CI 1.2 to 2.8). Women exposed to both tools were generally at least twice as likely to subsequently discuss the messages with others. BBC Media Action's mHealth audio messaging job aids and paper-based IPC tools were associated with improved knowledge and practices of women who were exposed to them across multiple domains, suggesting their important potential for improving health outcomes for beneficiaries at scale in low-resource settings. NCT02726230.

In the Ethiopian health system, operations management techniques have been underutilised. Although previous research has outlined limitations of paper-based patient records, few studies have examined their potential utility for improving management of hospital operations. In this paper, we used data collected from paper registries in an Ethiopian obstetrics ward at Addis Ababa’s Tikur Anbessa Specialized Hospital, Ethiopia’s largest university hospital, to model the ward’s operations. First, we attempted to identify predictors of lengthy stays and readmissions among women giving birth: few predictors were deemed significant. Second, time series methods for demand forecasting were applied to the data and evaluated with several error metrics, and these forecasts were improvements over baseline methods. We conclude with recommendations on how the obstetrics ward could incorporate our modelling approaches into their daily operations.

Introduction Obtaining informed consent for research includes the use of information sheets, which are often long and may be difficult for participants to understand. We conducted a trial to investigate whether consent procedures using a study information video coupled with electronic consent were non-inferior to standard consent procedures using participant information sheets (PIS) among youth aged 18–24 years in Zimbabwe.Methods The trial was nested within an endline population-based survey for a cluster-randomised trial from October 2021 to June 2022. Randomisation of participants to video or paper-based consent was at household level. We assessed non-inferiority in comprehension of the study using a questionnaire. The video method was accepted as non-inferior to standard consent procedures if the 95% CIs of the mean difference did not fall below the prespecified margin of 1.98. Thematic analysis was conducted on brief qualitative discussions with randomly selected youth to explore the acceptability of video and PIS within consent methods.Results Overall, 921 participants were enrolled (54% female). The median age was 20 (IQR 18–24) years. The mean comprehension score was 25.4/30 in both arms. The mean difference in comprehension between arms was −0.02 (95% CI −0.51 to 0.47) showing non-inferiority of the intervention in comprehension of study information. Youth (N=90) described both consent methods as interactive and inclusive. Those in the video consent arm felt it was exciting and youth focused. The use of imagery to explain procedures strengthened the perceived trustworthiness of the research. However, the high volume of information in both arms reduced acceptability.Conclusion Comprehension of study information using an information video is non-inferior to a paper-based consent method. Using information videos for consent processes shows promise as a person-centred and context-sensitive approach to enhance the informed consent process and should be encouraged by ethics committees.

Introduction Gypsies, Roma and Travellers (GRT) frequently experience poorer health outcomes than the general population and represent the most socially and economically disadvantaged individuals in many countries. In general, GRT in OECD (Organisation for Economic Co-operation and Development) countries have lower rates of literacy than the general population. Although ‘health literacy’ has been examined before, the link between low functional literacy and its effects on health has not yet been explored.Methods Searches were conducted on five large English-language databases for research papers since 2008. Grey literature was included as the number of eligible papers was small. This was complimented by citation ‘chaining’. Study findings of qualitative papers were extracted, codes were devised and then analysed thematically. A narrative synthesis was reported, supplemented by the quantitative findings.Results 15 studies (and two substudies) were analysed. Four strongly overlapping themes were developed: (1) The context of culturally inadequate healthcare systems, (2) psychological impact and disempowerment, (3) intersectional, contextual factors and the unique needs of GRT and (4) considerations for health information resources for GRT patients with low literacy.Conclusion Although low literacy in GRT groups is a well-recognised issue, this is the first systematic review to analyse the link between low literacy and its effects on health outcomes for GRT. The wide range of socioeconomic and cultural factors present in GRT communities, combined with low literacy, act synergistically to worsen the physical and mental health of GRT groups in different ways than that seen in members of the general population with similar low literacy levels. National intervention is required to improve the literacy of GRT children and adults. There is a clear need to develop policies and processes that facilitate a better understanding of literacy levels and how they interact with other social determinants of GRT health among healthcare professionals.Registration number CRD42023468449.

Enhancing digital health governance is critical to healthcare systems in low-income and middle-income countries. However, implementing governance-enhancing reforms in these countries is often challenging due to the multiplicity of external players and insufficient operational guidance that is accessible. Using data from desktop research, in-depth interviews, focus group discussions and three stakeholder workshops, this paper aims to provide insights into Georgia’s experience in advancing digital health governance reforms. It reveals how Georgia has progressed on this path by unpacking the general term ‘governance’ into operational domains, where stakeholders and involved institutions could easily relate their institutional and personal roles and responsibilities with the specific function needed for digital health. Based on this work, the country delineated institutional responsibilities and passed the necessary regulations to establish better governance arrangements for digital health. The Georgia experience provides practical insights into the challenges faced and solutions found for advancing digital health governance in a middle-income country setting. The paper highlights the usefulness of operational definitions for the digital health governance domains that helped (a) increase awareness among stakeholders about the identified domains and their meaning, (b) discuss possible governance and institutional arrangements relevant to a country context, and (c) design the digital health governance architecture that the government decreed. Finally, the paper offers a broad description of domains in which the governance arrangements could be considered and used for other settings where relevant. The paper points to the need for a comprehensive taxonomy for governance domains to better guide digital health governance enhancements in low-middle-income country settings.

Introduction Low-income and middle-income countries (LMICs) have a high burden of herpes simplex virus type 2 (HSV-2) infection, which has been strongly associated with HIV. In 2001, the WHO hosted a workshop to set research priorities for HSV-2 in LMICs. Periodic re-evaluation of research priorities is essential to ensure effective allocation of resources. This study describes the progress made between 2000 and 2020 in addressing the priorities identified in two of the five thematic areas that were the workshop’s focus: HSV-2 epidemiology and diagnostics. The remaining areas are addressed in a companion paper.Methods A systematic search of MEDLINE, CINAHL, Global Health and Cochrane databases was carried out. Relevant primary and secondary research studies conducted in LMICs, written in English and published from 2000–2020 were included. Two independent researchers screened, identified papers and extracted preidentified variables from study texts. Data were organised into an Excel spreadsheet and analysed using IBM SPSS V.26.Results Overall, 4445 discrete papers were identified, of which 165 publications were eligible for inclusion. The highest general population HSV-2 prevalence was reported in South and West Africa. Prevalence was higher among women than men and increased with age. HSV-2 prevalence studies among key populations were few, and the majority were in East and South Asia. Cohort studies of HSV-2 incidence among younger populations (mean age=25 years) and HSV-2 infection prevalence in North Africa and the Middle East were few. The most researched topic in HSV-2 diagnostics addressed serological techniques and direct molecular biology. Studies of point-of-care testing were also few.Conclusion HSV-2 research identified in LMICs has mainly addressed the epidemiology and diagnostics priorities identified by the 2001 WHO workshop. Unaddressed priorities include point-of-care testing, antiviral resistance and exploration of HSV-2 epidemiology in neglected geographical settings and population subgroups.

Introduction Reviewing and updating research priorities is essential to assess progress and to ensure optimal allocation of financial and human resources in research. In 2001, WHO held a research priority setting workshop for herpes simplex virus type 2 (HSV-2) research in low-income and middle-income countries (LMICs). This study aimed to describe progress between 2000 and 2020 in three of the five key research priority areas outlined in the workshop: HSV-2/HIV interactions, HSV-2 control measures and HSV-2 mathematical modelling. The remaining priorities are addressed in a companion paper.Method A systematic literature search of MEDLINE, CINAHL, Global Health and Cochrane databases was carried out. Relevant primary research studies based in LMICs, written in English and published on 2000–2020 were included. Papers were screened by two independent reviewers, and suitable variables were selected for manual extraction from study texts. Data were organised into an Excel spreadsheet and analysed using IBM SPSS.Results In total, 3214 discrete papers were identified, of which 180 were eligible for inclusion (HSV-2/HIV interactions, 98; control measures, 58; mathematical modelling, 24). Most studies were conducted in East Africa. The majority of the 2001 WHO HSV-2 research priorities were addressed at least in part. Overall, despite several studies describing a strong relationship between HSV-2 and the acquisition and transmission of HIV, HSV-2 control repeatedly demonstrated little effect on HIV shedding or transmission. Further, although mathematical modelling predicted that vaccines could significantly impact HSV-2 indicators, HSV-2 vaccine studies were few. Studies of antiviral resistance were also few.Conclusion Since 2000, LMIC HSV-2 research addressing its control, HIV interactions and mathematical modelling has largely addressed the priorities set in the 2001 WHO HSV-2 workshop. However, key knowledge gaps remain in vaccine research, antiviral cost-effectiveness, antiviral resistance and specific geographical areas.

Introduction Race and gender were intimately intertwined aspects of the colonial project, used as key categories of hierarchisation within both colonial and modern societies. As such, true decolonisation is only possible when both are addressed equally; failure to address the colonial root causes of gender-based inequalities will allow for the perpetuation of racialised notions of gender to persist across the global health ecosystem. However, the authors note with concern the relative sidelining of gender within the decolonising global health discourse, especially as it navigates the critical transition from rhetoric to action.Methods A scoping review was conducted to locate where gender does, or does not, appear within the decolonising global health literature. The authors reviewed the decolonising global health literature available on Scopus and PubMed online databases to identify peer-reviewed papers with the search terms (decoloni* or de-coloni*) OR (neocolonial or neo-colonial) AND global health in their title, abstract or keywords published by December 2022.Results Out of 167 papers on decolonising global health, only 53 (32%) had any reference to gender and only 26 (16%) explicitly engaged with gender as it intersects with (de)coloniality. Four key themes emerged from these 26 papers: an examination of coloniality’s racialised and gendered nature; how this shaped and continues to shape hierarchies of knowledge; how these intertwining forces drive gendered impacts on health programmes and policies; and how a decolonial gender analysis can inform action for change.Conclusion Historical legacies of colonisation continue to shape contemporary global health practice. The authors call for the integration of a decolonial gender analysis in actions and initiatives that aim to decolonise global health, as well as within allied movements which seek to confront the root causes of power asymmetries and inequities.

A comprehensive evidence-based framework is needed to guide policies and programmes that enable children and adolescents to accrue the human capital required to meet the Sustainable Development Goals (SDGs). This paper proposes a comprehensive, multisectoral, multilevel life-course conceptualisation of human capital development by building on the Nurturing Care Framework (NCF), originally developed for the foundational period of growth and development through the age 3 years. Nurturing care (NC) comprises stable environments that promote children's health and nutrition, protect from threats, and provide opportunities for learning and responsive, emotionally supportive and developmentally enriching relationships. NC is fostered by families, communities, services, national policies and beyond. The principles apply across the life course, endorse equity and human rights, and promote long-term human capital. This paper presents an evidence-based argument for the extension of the NCF from preconception through adolescence (0-20 years), organised into six developmental periods: preconception/prenatal, newborn/birth, infancy/toddlerhood, preschool, middle childhood and adolescence. The proposed framework advances human capital within each developmental period by promoting resilience and adaptive developmental trajectories while mitigating negative consequences of adversities.Attaining the SDGs depends on strengthening human capital formation, extending throughout childhood and adolescence and supported by NC. Embedded in enabling laws, policies and services, the dynamic NCF components can mitigate adversities, enhance resilience and promote the well-being of marginalised groups. The life-course extension of the NCF is strategically positioned to enhance human capital, to attain the SDGs and to ensure that children or adolescents are not left behind in reaching their developmental potential.

Aboriginal and Torres Strait Islander people in Australia face disparities in accessing culturally safe and appropriate health services. While current cultural safety and responsiveness frameworks set standards for improving healthcare practices, ensuring accountability and sustainability of changes, necessitates robust mechanisms for auditing and monitoring progress. This study examined existing cultural safety audit tools, and facilitators and barriers to implementation, in the context of providing culturally safe and responsive healthcare services with Aboriginal and Torres Strait Islander people. This will assist organisations, interested in developing tools, to assess culturally responsive practice. A scoping review was undertaken using Medline, Scopus, CINAHL, Informit and PsychInfo databases. Articles were included if they described an audit tool used for healthcare practices with Aboriginal and Torres Strait Islander people. Selected tools were evaluated based on alignment with the six capabilities of the Indigenous Allied Health Australia (IAHA) Cultural Responsiveness in Action Framework. Implementation barriers and facilitators were identified. 15 papers were included. Audit tools varied in length, terminology, domains assessed and whether they had been validated or evaluated. Seven papers reported strong reliability and validity of the tools, and one reported tool evaluation. Implementation facilitators included: tool comprehensiveness and structure; effective communication; clear organisational responsibility for implementation; commitment to prioritising cultural competence; and established accountability mechanisms. Barriers included: the tool being time-consuming and inflexible; responsibility for implementation falling on a small team or single staff member; deprioritising tool use; and lack of accountability for implementation. Two of the six IAHA capabilities (respect for the centrality of cultures and inclusive engagement) were strongly reflected in the tools. The limited tool evaluation highlights the need for further research to determine implementation effectiveness and sustainability. Action-oriented tools, which comprehensively reflect all cultural responsiveness capabilities, are lacking and further research is needed to progress meaningful change within the healthcare system.

Drawing on two recent examples of WHO living guidelines in maternal and perinatal health, this paper elucidates a pragmatic, stepwise approach to using network meta-analysis (NMA) in guideline development in the presence of multiple treatment options. NMA has important advantages. These include the ability to compare multiple interventions in a single coherent analysis, provide direct estimates of the relative effects of all available interventions, infer indirect effect estimates for interventions not directly compared and generate rankings of the available treatment options. It can be difficult to harness these advantages in the face of a lack of current guidance on using NMA evidence in guideline development, with several challenges emerging. Challenges include the choice of conceptual approach, the volume and complexity of the evidence, the contribution of treatment rankings, and the fact that the preferable treatment is not always obvious. This paper describes a layered approach to resolving these challenges, which supports systematic guideline decision-making and development of trustworthy clinical guidelines when multiple treatment options are available.

The African Region reports the heaviest burden of public health emergencies globally. This paper presents an exploratory analysis of public health events data collected the past 22 years in the WHO Africa region, to explore patterns and trends that can inform public health strategies, policy changes and develop appropriate tools to improve disease surveillance, preparedness and response to public health emergencies. A suite of exploratory data analysis methods combining time series analysis, summary statistics, temporal visualisations, geographic information system (GIS) mapping, trend analysis and statistical tests were used to derive patterns and trends from the data. An in-depth analysis of zoonotic disease outbreaks by geography and time was explored. The analysis also focused on whether these outbreaks were viral haemorrhagic related or had other characteristics. Results reveal that between 2001 and 2022, a total of 2234 public health events have been recorded in the WHO African Region of which 1886 events (84.4%) were substantiated. The paper confirms an average of 102 public health events reported yearly during the last 22 years time frame. The large majority (92%) of the substantiated events were infectious diseases (n=1730), 30% (n=566) are zoonoses and 5% (n=95) are humanitarian crises such as disaster events and conflicts. The number of zoonotic disease outbreaks has significantly increased (by 87%) between the past two decades, from 2003 to 2012 period (M=18.6, SD=4.8) and 2013–2022 period (M=34.7, SD=14); t(18) = 3.4, p=0.0032. This analysis shows growing challenges faced in the Africa region every year. One-health approach and its coordination across multiple sectors, disciplines and communities is critical to achieve the objectives.

The past four decades have seen a steady rise of references to ‘security’ by health academics, policy-makers and practitioners, particularly in relation to threats posed by infectious disease pandemics. Yet, despite an increasingly dominant health security discourse, the many different ways in which health and security issues and actors intersect have remained largely unassessed and unpacked in current critical global health scholarship. This paper discusses the emerging and growing health-security nexus in the wake of COVID-19 and the international focus on global health security. In recognising the contested and fluid concept of health security, this paper presents two contrasting approaches to health security: neocolonial health security and universal health security. Building from this analysis, we present a novel heuristic that delineates the multiple intersections and entanglements between health and security actors and agendas to broaden our conceptualisation of global health security configurations and practices and to highlight the potential for harmful unintended consequences, the erosion of global health norms and values, and the risk of health actors being co-opted by the security sector.

IntroductionThe rising burden of diabetes in low- and middle-income countries may cause financial strain on individuals and health systems. This paper presents a systematic review of direct medical costs for diabetes (types 1 and 2) in low- and middle-income countries.MethodsFollowing Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, databases (PubMed, International Bibliography of Social Science, EconLit) were searched for publications reporting direct medical costs of type 1 and 2 diabetes. Data were extracted from all peer-reviewed papers meeting inclusion criteria, and were standardised into per-patient-visit, per-patient-year and/or per-complication-case costs (2016 US$).ResultsThe search yielded 584 abstracts, and 52 publications were included in the analysis. Most articles were from Asia and Latin America, and most focused on type 2 diabetes. Per-visit outpatient costs ranged from under $5 to over $40 (median: $7); annual inpatient costs ranged from approximately $10 to over $1000 (median: $290); annual laboratory costs ranged from under $5 to over $100 (median: $25); and annual medication costs ranged from $15 to over $500 (median: $177), with particularly wide variation found for insulin. Care for complications was generally high-cost, but varied widely across countries and complication types.ConclusionThis review identified substantial variation in diabetes treatment costs; some heterogeneity could be mitigated through improved methods for collecting, analysing and reporting data. Diabetes is a costly disease to manage in low- and middle-income countriesand should be a priority for the global health community seeking to achieve Universal Health Coverage.

There was, and possibly still is, potential for COVID-19 to disrupt power inequities and contribute to positive transformation in global health research that increases equity. While there is consensus about the need to decolonise by transforming global health, and a roadmap outlining how we could approach it, there are few examples of steps that could be taken to transform the mechanics of global health research. This paper contributes lessons learnt from experiences and reflections of our diverse multinational team of researchers involved in a multicountry research project. We demonstrate the positive impact on our research project of making further steps towards improving equity within our research practices. Some of the approaches adopted include redistributing power to researchers from the countries of interest at various stages in their career, by involving the whole team in decisions about the research; meaningfully involving the whole team in research data analysis; and providing opportunities for all researchers from the countries of interest to voice their perspectives as first authors in publications. Although this approach is consistent with how research guidance suggests research should be run, in reality it does not often happen in this way. The authors of this paper hope that by sharing our experience, we can contribute towards discussions about the processes required to continue developing a global health sector that is equitable and inclusive.

COVID-19 has highlighted the importance of essential public health functions (EPHFs) and the coordination between them. The US Centers for Disease Control and Prevention defines EPHFs as ‘the public health activities that all communities should undertake’. According to multiple functional frameworks published in literature, the functions typically include workforce development, surveillance, public health research, laboratory services, health promotion, outbreak response and emergency management. National Public Health Institutes (NPHIs) are often the lead government agency responsible for execution of these functions.This paper describes how NPHIs or other health authorities can improve public health impact by enhancing the coordination of public health functions and public health actors through functional and organisational linkages. We define public health linkages as practical, replicable activities that facilitate collaboration between public health functions or organisations to improve public health. In this paper, we propose a novel typology to categorise important public health linkages and describe enablers of linkages identified through our research.Based on our research, investments in health systems should move beyond vertical approaches to developing public health capacity and place greater emphasis on strengthening the interactions between public health functions and institutions. Development of linkages and their enablers require a purposeful, proactive focus that establishes and strengthens linkages over time and cannot be developed during an outbreak or other public health emergency.

Introduction Migrants’ access to sexual and reproductive health (SRH) services is constrained by several individual, organisational and structural barriers. To address these barriers, many interventions have been developed and implemented worldwide to facilitate the access and utilisation of SRH services for migrant populations. The aim of this scoping review was to identify the characteristics and scope of interventions, their underlying theory of change, reported outcomes and key enablers and challenges to improve access to SRH services for migrants.Methods A scoping review was conducted according to the Arksey and O’Malley (2005) guidelines. We searched three electronic databases (MEDLINE, Scopus and Google Scholar) and carried out additional searches using manual searching and citations tracking of empirical studies addressing interventions aimed at improving access and utilisation of SRH services for migrant populations published in Arabic, French or English between 4 September 1997 and 31 December 2022.Results We screened a total of 4267 papers, and 47 papers met our inclusion criteria. We identified different forms of interventions: comprehensive (multiple individual, organisational and structural components) and focused interventions addressing specific individual attributes (knowledge, attitude, perceptions and behaviours). Comprehensive interventions also address structural and organisational barriers (ie, the ability to pay). The results suggest that coconstruction of interventions enables the building of contextual sensitive educational contents and improved communication and self-empowerment as well as self-efficacy of migrant populations, and thus improved access to SRH.Conclusion More attention needs to be placed on participative approaches in developing interventions for migrants to improve access to SRH services.

High-quality peer-reviewer training open to researchers across the globe has the potential to improve the published literature, however, this type of training is not widely available. In this paper, we describe an online peer-reviewer training programme, highlight its effectiveness in building peer review and writing skills, and discuss challenges and lessons learnt. This training programme, open to researchers across the globe, acquaints participants with challenges to and inequities in publishing and educates them about writing effective peer reviews. A focal point is how to provide specific and respectful feedback to help authors get accepted for peer review at an academic journal. Forty-nine participants from or residing in six continents completed the training. All programme evaluation respondents agreed that the orientation helped them gain a better understanding of their role as a peer reviewer at Pre-Publication Support Service. Most agreed that the training was helpful in improving their peer-review skills, and that the training was helpful in improving their writing skills. Participants wanted more networking and collaboration opportunities with other peer reviewers, inclusion of a qualitatively researched example paper and improved communication about the required time commitment. Our online programme with multiple time options was geographically inclusive but internet connectivity was challenging for some participants. Peer-reviewer training programmes can help researchers build their peer review and writing skills and enhance participants’ understanding of disparities in publishing. Integrating a geographically diverse group of researchers has the potential to enrich the discussions and learning in such a programme.

Public health research and human rights bodies have demonstrated the risks involved with criminalising abortion services and noted a need for full decriminalisation. Despite this, abortions are criminalised in some circumstances in almost all countries in the world today. This paper uses data from the Global Abortion Policies Database (GAPD) to analyse what criminal penalties exist for those who are seeking, providing and assisting in abortions in 182 countries.This paper uses data on abortion-related penalties available on the GAPD as of October 2022. It includes which actors are penalised, whether specific penalties exist for negligence, non-consensual abortions, whether any secondary additional considerations/judicial discretion exist in sentencing and the legal sources for these penalties.134 countries penalise abortion-seekers, 181 countries penalise abortion-providers and 159 countries penalise persons assisting in abortions. The maximum penalty is between 0 and 5 years of imprisonment in a majority of countries; however, it can be much higher in other countries. Some countries further prescribe fines, and professional sanctions for providers and those who assist. 34 countries restrict the dissemination of information about abortion.The range of possible penalties across countries and associated aggravating and mitigating factors for imposing these penalties support arguments for the decriminalisation of abortion on the grounds of arbitrariness. Abortions are also predominantly regulated through the criminal law, which may compound the stigma associated with seeking, assisting with and/or providing abortions when it is criminalised.There has been no comprehensive study of penalties for abortion at a global level. This article describes what specific penalties abortion seekers and providers face, what factors may increase or decrease these penalties, and the legal sources for these penalties. The findings provide additional evidence of the arbitrariness and potential for stigma associated with the criminalisation of abortion and strengthen the case for decriminalisation.

Background Authors from low and middle-income country (LMIC) institutions are under-represented in publications of research based in LMICs. This case study of publications from authors within the Medical Research Council International Statistics and Epidemiology Group (MRC-ISEG), a global health research group affiliated to the London School of Hygiene & Tropical Medicine in the UK, aims to describe patterns in authorship and factors associated with under-representation.Methods Papers were included if they were published between January 2016 and December 2020 inclusive, included an author from the MRC-ISEG and described work conducted in a LMIC. Authors’ affiliations were classified using World Bank country income classifications into LMIC affiliations only, high-income country (HIC) affiliations only and mixed LMIC/HIC affiliations. Multinomial logistic regression analysis was used to assess associations of author affiliation category with authorship position, and whether patterns varied by journal impact factor quartile and multiple versus single-country studies.Results A total of 882 papers, including 10 570 authors describing research conducted in 61 LMICs, were included. Compared with authors of HIC-only affiliation, those with LMIC-only affiliation were less likely to be in first authorship position (relative risk ratio (RRR)=0.51, 95% CI 0.44 to 0.60) and mixed HIC/LMIC affiliation authors were more likely (RRR=2.80, 95% CI 2.35 to 3.34). Compared with authors of HIC-only affiliation, those with LMIC-only affiliation were less likely to be in last authorship position (RRR=0.20, 95% CI 0.16 to 0.24) and those with mixed HIC/LMIC affiliations were more likely (RRR=1.95, 95% CI 1.65 to 2.30). The proportion of senior authors with LMIC-only affiliation was lowest for the highest impact journals, and in multicountry versus single-country studies.Conclusion Alongside increasing research capacity within LMICs, HIC institutions should ensure that LMIC-affiliated researchers are properly represented in global research. Academics working in global health should be judged on their involvement in representative collaborative research rather than individual achievements in authorship position.

Introduction With the ratification of the Sustainable Development Goals, there is an increased emphasis on early childhood development (ECD) and well-being. The WHO led Global Scales for Early Development (GSED) project aims to provide population and programmatic level measures of ECD for 0–3 years that are valid, reliable and have psychometrically stable performance across geographical, cultural and language contexts. This paper reports on the creation of two measures: (1) the GSED Short Form (GSED-SF)—a caregiver reported measure for population-evaluation—self-administered with no training required and (2) the GSED Long Form (GSED-LF)—a directly administered/observed measure for programmatic evaluation—administered by a trained professional.Methods We selected 807 psychometrically best-performing items using a Rasch measurement model from an ECD measurement databank which comprised 66 075 children assessed on 2211 items from 18 ECD measures in 32 countries. From 766 of these items, in-depth subject matter expert judgements were gathered to inform final item selection. Specifically collected were data on (1) conceptual matches between pairs of items originating from different measures, (2) developmental domain(s) measured by each item and (3) perceptions of feasibility of administration of each item in diverse contexts. Prototypes were finalised through a combination of psychometric performance evaluation and expert consensus to optimally identify items.Results We created the GSED-SF (139 items) and GSED-LF (157 items) for tablet-based and paper-based assessments, with an optimal set of items that fit the Rasch model, met subject matter expert criteria, avoided conceptual overlap, covered multiple domains of child development and were feasible to implement across diverse settings.Conclusions State-of-the-art quantitative and qualitative procedures were used to select of theoretically relevant and globally feasible items representing child development for children aged 0–3 years. GSED-SF and GSED-LF will be piloted and validated in children across diverse cultural, demographic, social and language contexts for global use.

Background Lack of political will is frequently invoked as a rhetorical tool to explain the gap between commitment and action for health reforms in sub-Saharan Africa (SSA). However, the concept remains vague, ill defined and risks being used as a scapegoat to actually examine what shapes reforms in a given context, and what to do about it. This study sought to go beyond the rhetoric of political will to gain a deeper understanding of what drives health reforms in SSA.Methods We conducted a scoping review using Arksey and O’Malley (2005) to understand the drivers of health reforms in SSA.Results We reviewed 84 published papers that focused on the politics of health reforms in SSA covering the period 2002–2022. Out of these, more than half of the papers covered aspects related to health financing, HIV/AIDS and maternal health with a dominant focus on policy agenda setting and formulation. We found that health reforms in SSA are influenced by six; often interconnected drivers namely (1) the distribution of costs and benefits arising from policy reforms; (2) the form and expression of power among actors; (3) the desire to win or stay in government; (4) political ideologies; (5) elite interests and (6) policy diffusion.Conclusion Political will is relevant but insufficient to drive health reform in SSA. A framework of differential reform politics that considers how the power and beliefs of policy elites is likely to shape policies within a given context can be useful in guiding future policy analysis.

Introduction Research is a critical pillar in national cancer control planning. However, there is a dearth of evidence for countries to implement affordable strategies. The WHO and various Commissions have recommended developing stakeholder-based needs assessments based on objective data to generate evidence to inform national and regional prioritisation of cancer research needs and goals.Methodology Bibliometric algorithms (macros) were developed and validated to assess cancer research outputs of all 54 African countries over a 12-year period (2009–2020). Subanalysis included collaboration patterns, site and domain-specific focus of research and understanding authorship dynamics by both position and sex. Detailed subanalysis was performed to understand multiple impact metrics and context relative outputs in comparison with the disease burden as well as the application of a funding thesaurus to determine funding resources.Results African countries in total published 23 679 cancer research papers over the 12-year period (2009–2020) with the fractional African contribution totalling 16 201 papers and the remaining 7478 from authors from out with the continent. The total number of papers increased rapidly with time, with an annual growth rate of 15%. The 49 sub-Saharan African (SSA) countries together published just 5281 papers, of which South Africa’s contribution was 2206 (42% of the SSA total, 14% of all Africa) and Nigeria’s contribution was 997 (19% of the SSA total, 4% of all Africa). Cancer research accounted for 7.9% of all African biomedical research outputs (African research in infectious diseases was 5.1 times than that of cancer research). Research outputs that are proportionally low relative to their burden across Africa are paediatric, cervical, oesophageal and prostate cancer. African research mirrored that of Western countries in terms of its focus on discovery science and pharmaceutical research. The percentages of female researchers in Africa were comparable with those elsewhere, but only in North African and some Anglophone countries.Conclusions There is an imbalance in relevant local research generation on the continent and cancer control efforts. The recommendations articulated in our five-point plan arising from these data are broadly focused on structural changes, for example, overt inclusion of research into national cancer control planning and financial, for example, for countries to spend 10% of a notional 1% gross domestic expenditure on research and development on cancer.

Since the first administration of COVID-19 vaccine in December 2020, countries have experienced a range of challenges at different phases of their COVID-19 vaccination programmes. Initially, with limited global COVID-19 vaccine supply, the WHO called for vaccine equity to ensure the most vulnerable people in every country globally had access to vaccine, and COVID-19 Vaccines Global Access was established to facilitate equitable access to COVID-19 vaccine. However, the aims of these initiatives were challenged as many countries secured earlier access to COVID-19 vaccine with direct agreements with manufacturers. During the early stages of COVID-19 vaccination programmes, the rate of vaccine uptake was determined by number of COVID-19 vaccines approved for use and the manufacturing capacity of the manufacturers of these vaccines. It is a very different situation in 2022, where COVID-19 vaccination coverage is no longer determined by access to supply and manufacturers are reducing or stopping production of vaccines completely. Uptake of COVID-19 vaccination in 2022 is dependent on complex issues like vaccine hesitancy. This paper focuses on the Central and West Asia region, where the authors have been supporting COVID-19 vaccination programmes across seven countries in this region. In this paper, we outline and describe the different phases of demand for COVID-19 vaccination as well as the risks and strategies to consider in each of these phases.

Despite primary healthcare (PHC) being recognised in global declarations—Alma Ata in 1978 and Astana in 2018—and prioritised in national health strategies, chronic under-resourcing of PHC persists in most low-income and middle-income countries. More public spending is needed for PHC, but macrofiscal and political constraints often limit the ability of governments to allocate more public resources to PHC. Under-resourcing has been compounded by fragmented and rigid funding flows, which are inefficient and may erode equity, quality of care and public trust in PHC.This article explores the drivers of fragmentation in PHC financing—low public spending, which results in over-reliance on external sources to fund critical health interventions, and the proliferation of new financing schemes that do not take a system-wide view or adhere to the principles of universality. It then highlights some of the possible consequences of this fragmentation for the efficiency, equity and effectiveness of service delivery.Four countries—Argentina, Burkina Faso, Indonesia and Tanzania—are used to illustrate practical steps that may be taken to minimise the consequences of fragmentation in PHC financing: (1) consolidating multiple coverage schemes, (2) avoiding further fragmentation, (3) harmonising health purchasing functions and (4) streamlining funding flows to the provider level.The country examples reveal lessons for policy-makers grappling with the consequences of fragmented PHC financing. The paper concludes with a research agenda to generate additional evidence on what works to address fragmentation.

Conscientious objection is a critical topic that has been sparsely discussed from a global health perspective, despite its special relevance to our inherently diverse field. In this Analysis paper, we argue that blanket prohibitions of a specific type of non-discriminatory conscientious objection are unjustified in the global health context. We begin both by introducing a nuanced account of conscience that is grounded in moral psychology and by providing an overview of discriminatory and non-discriminatory forms of objection. Next, we point to the frequently neglected but ubiquitous presence of moral uncertainty, which entails a need for epistemic humility—that is, an attitude that acknowledges the possibility one might be wrong. We build two arguments on moral uncertainty. First, if epistemic humility is necessary when dealing with values in theory (as appears to be the consensus in bioethics), then it will be even more necessary when these values are applied in the real world. Second, the emergence of global health from its colonial past requires special awareness of, and resistance to, moral imperialism. Absolutist attitudes towards disagreement are thus incompatible with global health’s dual aims of reducing inequity and emerging from colonialism. Indeed, the possibility of global bioethics (which balances respect for plurality with the goal of collective moral progress) hinges on appropriately acknowledging moral uncertainty when faced with inevitable disagreement. This is incompatible with blanket prohibitions of conscientious objection. As a brief final note, we distinguish conscientious objection from the problem of equitable access to care. We note that conflating the two may actually lead to a less equitable picture on the whole. We conclude by recommending that international consensus documents, such as the Universal Declaration on Bioethics and Human Rights, be amended to include nuanced guidelines regarding conscientious objection that can then be used as a template by regional and national policymaking bodies.

Background There has been much critical reflection among global health researchers about how power imbalances between high-income countries and low- and middle-income country collaborators are perpetuated through research programmes. Research capacity strengthening (RCS) is considered both a mechanism through which to redress structural power imbalances in global health research and a vehicle for their perpetuation. This paper examines the RCS programme of a multi-county study on violence against women, focussing on how it addressed power imbalances between countries and the challenges involved in doing so. It provides specific examples and lessons learnt.Methods 18 semi-structured interviews were conducted online with group members from all five countries involved in the collaboration between April and June 2020. Reflexive thematic analysis, with inductive and deductive approaches was adopted.Findings Participants articulated their understandings of RCS as an opportunity for (1) mutual learning, understanding and collaboration and (2) personal and team career development. Participants perceived the RCS programme activities to simultaneously reinforce and challenge power asymmetries within global health research. Power dynamics within the RCS programme operated across three levels; the global health research environment, the research group level and within individual country teams. Participants described structural barriers at all three levels, but felt there were more opportunities to challenge power imbalances at the research group level.Conclusion Despite a strong commitment to addressing power imbalances through the RCS programme, progress was often hampered by the fact that these inequalities reflected broader structural issues in global health, as seen within Healthcare Responding to Violence and Abuse. The programme sometimes faced tensions between enhancing researchers’ careers while building capacity under the current model and creating social value or challenging epistemic and normative structures. Participants clearly expressed concerns about power imbalances within the partnership and were keen to address them through the RCS programme. This led to a steep learning curve and significant adaptations within the RCS programme to navigate these issues within existing structural limitations.

Introduction Academic–government partnerships are important to advance timely, responsive and relevant evidence for decision-making (policy, guideline, law and regulation) deliberations. Deliberate and strategic integrated knowledge translation (KT) approaches within such partnerships have been shown to facilitate evidence-informed decision-making (EIDM). We used Cochrane’s KT Framework to map and analyse COVID-19 response activities instituted by a strategic academic-government partnership to support EIDM during the COVID-19 pandemic in South Africa.Methods We used Cochrane’s KT Framework to map and analyse COVID-19 response activities instituted by a strategic academic–government partnership to support EIDM during the COVID-19 pandemic in South Africa. The COVID-19 response activities included coproducing rapid therapeutics reviews, engaging stakeholders with review evidence, packaging and disseminating review products, facilitating access to rapid reviews for evidence users and adapting partnership processes for rapid review production.Results This paper highlights the importance of (a) authentic partnerships between evidence producers and users (motivated by context-specific goals, trust and relationships); (b) intentional and systematic stakeholder engagement to promote the rapid exchange of information; (c) using tailored, responsive and relevant KT to promote the uptake of evidence and (d) monitoring and evaluating the implementation of KT to identify lessons learnt and adaptation of KT approaches.Conclusion In responding to future emergencies, a comprehensive KT strategy, including the expertise of KT practitioners and science communicators to make evidence and guideline recommendations accessible, should be embedded. Additionally, streamlining bureaucratic processes for approving and communicating information; identifying and addressing decision-maker capacity needs; engaging a range of stakeholders and integrating KT in usual decision-making processes, is recommended. Adequate investment by governments is needed for sustaining KT approaches that can enhance EIDM for improving public health outcomes.

This practice paper reflects on an ongoing Participatory Action Research project that combines community-engaged methods, national data analysis and advocacy to support community-based emergency response to extreme weather events in 16 Indigenous communities in Alta Verapaz province, Guatemala. Our work points to a worrying predicament experienced in climate-affected areas, where some populations face a dangerous confluence of climate vulnerability, social exclusion and state abandonment that imperils human health. Indigenous communities in Alta Verapaz are often particularly vulnerable to health impacts from climate-driven extreme weather events, a reality compounded by the historical and contemporary ways the state marginalises them. We share work from our project activities to shed light on these interconnected problems and how Indigenous communities in Alta Verapaz, especially Maya Q’eqchi’ communities, are using creative strategies to confront them. Technical solutions are important but insufficient responses. Community-led activism to push for state support to address extreme weather events, as has been practised in struggles for health rights, can provide vital tools for addressing the increasing challenges these populations face in the context of the climate crisis.

Equitable health research requires actively engaging communities in producing new knowledge to advocate for their health needs. Community-based participatory research (CBPR) relies on the coproduction of contextual and grounded knowledge between researchers, programme implementers and community partners with the aim of catalysing action for change. Improving coproduction competencies can support research quality and validity. Yet, frameworks and guidance highlighting the ideal competencies and conditions needed for all research partners to contribute meaningfully and equitably are lacking. This paper aims to advance CBPR by laying out seven core competencies and conditions that can promote power sharing in knowledge production, application and dissemination at the individual, community, organisational and systems levels.Competencies were developed through an iterative process, that synthesised pre-existing literature and frameworks with a wide range of tacit knowledge from researchers, activists, implementation partners and community researchers from Bangladesh, India, Kenya, Sierra Leone and the UK.The seven core competencies and conditions are: (1) capacity to interpret and respond to individual and relational identity, connection, uniqueness and inequities; (2) ability of communities and partners to work in the most suitable, inclusive and synergistic way; (3) aptitude for generating safe and inclusive spaces for multidirectional knowledge and skills exchange that goes beyond the research focus; (4) expertise in democratic leadership and/or facilitation to balance competing priorities and ensure shared decision-making; (5) capacity to analyse readiness for action, successes and areas for improvements throughout the research process; (6) ability to instigate sustainable change processes within the political dimensions of systems, policies and practices using advocacy, lobbying or activism approaches and (7) skills to interpret and disseminate findings and outputs that are understandable, respectful and promote community ownership. We present core competency and condition areas, individual and collective expertise associated with competencies, likely outcomes, examples of activities and sources of evidence.

Introduction With shifts in international aid, international donors have increasingly regarded non-governmental organisations (NGOs) as capable of providing alternative public service arrangements. As funding flows to NGOs, particularly in contexts where both actors work towards strengthening health system resilience, NGO-donor relationships evolve. However, despite calls to investigate the contribution of relationships between actors within health systems, including NGOs and their donors, to health system resilience, empirical research is limited. Understanding these relationships is crucial for comprehending their role in fostering resilient health systems. This research fills this gap, by examining how NGO-donor coordination contributes to health system resilience in Lebanon.Methods This research focuses on Lebanon’s primary health system, primarily managed by NGOs through contracts and heavily funded by donors. It examines NGOs operating under the national primary healthcare network (PHCN). The participants, including staff from these NGOs and donor agencies funding them, were purposively selected. 31 semi-structured interviews were conducted. The analysis framework relied on a thematic analysis.Results The findings revealed that the flexibility in NGO-donor coordination in Lebanon depends on donors’ trust, regular coordination and donors’ willingness to listen to NGOs’ needs. In this light, they uncovered that flexible NGO-donor coordination enhances NGOs’ resilience capacities in shocks, allowing them to operate flexibly. By strengthening NGOs’ resilience, which contributes to the resilience of the broader health system, this relationship contributes to health system resilience.Conclusion The findings contradict the mainstream development literature on NGO-donor relationships. The latter focuses on donor funding requirements that often result in rigid NGO-donor coordination, making it difficult for NGOs to be resilient. Rather, they emphasise the donors’ role in implementing flexible development approaches, through flexible NGO-donor coordination, strengthening health system resilience. Overall, this paper contributes to the health system resilience literature by exploring how specific configurations of NGO-donor coordination strengthen health system resilience.

The field of ‘refugee health’ is generally understood in terms of the efforts of health professionals from a host country to provide care for humanitarian entrants. This paper attempts to undermine that idea, focusing instead on the service that health workers from refugee background communities are able to render, both to their own communities and to broader society, when barriers to their participation are made more equitable. The point of departure for this Practice paper is the 2019 pilot ‘Observership Program’ that was initiated by Mater Refugee Health in Brisbane, Australia. This was in response to, and in collaboration with, international medical graduates from refugee backgrounds. The two doctors who advocated for the programme had already independently embarked on a series of advocacy initiatives aimed at facilitating health workforce participation for members of their communities. In what follows we: outline the barriers to their medical registration and employment in Queensland, Australia; describe the process of setting up a 9-month clinical observership for two participants; and we reflect on the implications of the programme from a health policy and systems perspective. Ultimately, our contention is that because health systems are complex and adaptive, increased health workforce participation by members of marginalised communities has the potential to change the culture of the health system, making it more adept and responsive. Such, we propose, are the ‘ripple effects’ of addressing the obstacles to health workforce participation by members of refugee background communities.

Introduction Worldwide, people experience the effects of infectious disease outbreaks on a regular basis. These effects vary from direct impact of the virus on health, to indirect impact of control measures on day-to-day life. Yet, incorporating the experiences, views and ideas of patients and the public in decision-making in managing outbreaks does not take place on a structural basis. However, this might be beneficial. We examined the current incorporation of patient and public engagement (PPE) in decision-making regarding outbreak management (OM).Methods A systematic search was executed in PubMed, Embase, APA PsycInfo, Web of Science, Scopus and other literature sources. Papers describing PPE in decision-making regarding OM on a collective level (group-level) were included. Relevant information about study characteristics, methods, impact and embedment of PPE in decision-making in OM was collected.Results The search yielded 4186 papers of which 13 were included. The papers varied in study context and design. Remarkably, no substantial patient engagement was identified. Overall, public engagement (PE) in decision-making regarding OM was mostly executed by a mix of methods, for example, workshops, interviews and surveys. Knowledge and idea sharing between the public and experts was deemed beneficial for establishing well-informed discussions. The efforts resulted in either direct implications for practice or recommendations in policy papers. Most papers described their efforts as a first step. No structural embedment of collective PE in decision-making regarding OM was identified. Furthermore, the quality of most papers was low to moderate due to insufficient description.Conclusion Overall, various practices for PE can be potentially valuable, but structural embedment in OM decision-making on a collective level was low. Before PPE can be permanently embedded in OM, more evidence on its impact needs to be collected. Furthermore, reporting on the engagement process and used terminology needs to be harmonised to ensure reproducibility and transparency.

Existing performance management approaches in health systems in low-income and middle-income countries are generally ineffective at driving organisational-level and population-level outcomes. They are largely directive: they try to control behaviour using targets, performance monitoring, incentives and answerability to hierarchies. In contrast, enabling approaches aim to leverage intrinsic motivation, foster collective responsibility, and empower teams to self-organise and use data for shared sensemaking and decision-making.The current evidence base is too limited to guide reforms to strengthen performance management in a particular context. Further, existing conceptual frameworks are undertheorised and do not consider the complexity of dynamic, multilevel health systems. As a result, they are not able to guide reforms, particularly on the contextually appropriate balance between directive and enabling approaches. This paper presents a framework that attempts to situate performance management within complex adaptive systems. Building on theoretical and empirical literature across disciplines, it identifies interdependencies between organisational performance management, organisational culture and software, system-level performance management, and the system-derived enabling environment. It uses these interdependencies to identify when more directive or enabling approaches may be more appropriate. The framework is intended to help those working to strengthen performance management to achieve greater effectiveness in organisational and system performance. The paper provides insights from the literature and examples of pitfalls and successes to aid this thinking. The complexity of the framework and the interdependencies it describes reinforce that there is no one-size-fits-all blueprint for performance management, and interventions must be carefully calibrated to the health system context.

Health systems in sub-Saharan Africa have remained overstretched from dealing with endemic diseases, which limit their capacity to absorb additional stress from new and emerging infectious diseases. Against this backdrop, the rapidly evolving COVID-19 pandemic presented an additional challenge of insufficient hospital beds and human resource for health needed to deliver hospital-based COVID-19 care. Emerging evidence from high-income countries suggests that a ‘virtual ward’ (VW) system can provide adequate home-based care for selected patients with COVID-19, thereby reducing the need for admissions and mitigate additional stress on hospital beds. We established a VW at the Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, a biomedical research institution located in The Gambia, a low-income west African country, to care for members of staff and their families infected with COVID-19. In this practice paper, we share our experience focusing on the key components of the system, how it was set up and successfully operated to support patients with COVID-19 in non-hospital settings. We describe the composition of the multidisciplinary team operating the VW, how we developed clinical standard operating procedures, how clinical oversight is provided and the use of teleconsultation and data capture systems to successfully drive the process. We demonstrate that using a VW to provide an additional level of support for patients with COVID-19 at home is feasible in a low-income country in sub-Saharan Africa. We believe that other low-income or resource-constrained settings can adopt and contextualise the processes described in this practice paper to provide additional support for patients with COVID-19 in non-hospital settings.

This paper provides evidence that the COVID-19-related mortality rate of national government ministers and heads of state has been substantially higher than that of people with a similar sex and age profile in the general population, a trend that is driven by African cases (17 out of 24 reported deaths worldwide, as of 6 February 2021). Ministers’ work frequently puts them in close contact with diverse groups, and therefore at higher risk of contracting SARS-CoV-2, but this is not specific to Africa. This paper discusses five non-mutually exclusive hypotheses for the Africa-specific trend, involving comorbidity, poorly resourced healthcare and possible restrictions in accessing out-of-country health facilities, the underreporting of cases, and, later, the disproportionate impact of the so-called ‘South African’ variant (501Y.V2). The paper then turns its attention to the public health and political implications of the trend. While governments have measures in place to cope with the sudden loss of top officials, the COVID-19-related deaths have been associated with substantial changes in public health policy in cases where the response to the pandemic had initially been contested or minimal. Ministerial deaths may also result in a reconfiguration of political leadership, but we do not expect a wave of younger and more gender representative replacements. Rather, we speculate that a disconnect may emerge between the top leadership and the public, with junior ministers filling the void and in so doing putting themselves more at risk of infection. Opposition politicians may also be at significant risk of contracting SARS-CoV-2.

Despite progress in the development and evaluation of evidence-based primary mental health interventions in low-income and middle-income countries, implementation and scale-up efforts have had mixed results. Considerable gaps remain in the effective translation of research knowledge into routine health system practices, largely due to real-world contextual constraints on implementation and scale-up efforts. The Southern African Research Consortium for Mental Health Integration (S-MhINT) programme used implementation research to strengthen the implementation of an evidence-based integrated collaborative depression care model for primary healthcare (PHC) services in South Africa. To facilitate the scale-up of this model from a testing site to the whole province of KwaZulu-Natal, a capacity building programme was embedded within the Alliance for Health Policy and Systems Research (AHPSR) learning health systems (LHS) approach. The paper discusses efforts to scale up and embed case finding and referral elements of the S-MhINT package within routine PHC. Data from semistructured interviews, a focus group discussion, proceedings from participatory workshops and outputs from the application of continuous quality improvement (CQI) cycles were thematically analysed using the AHPSR LHS framework. Learning particularly occurred through information sharing at routine participatory workshops, which also offered mutual deliberation following periods of applying CQI tools to emergent problems. Individual-level, single-loop learning seemed to be particularly observable elements of the AHPSR LHS framework. Ultimately, our experience suggests that successful scale-up requires strong and sustained relationships between researchers, policy-makers and implementers, investments into learning platforms and organisational participation across all levels to ensure ownership and acceptance of learning processes.