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Background: It has been argued that quality improvements that result from user charges reduce their negative impact on utilization especially of the poor. In Uganda, because there was no concrete evidence for improvements in quality of care following the introduction of user charges, the government abolished user fees in all public health units on 1st March 2001. This gave us the opportunity to prospectively study how different aspects of quality of care change, as a country changes its health financing options from user charges to free services, in a developing country setting. The outcome of the study may then provide insights into policy actions to maintain quality of care following removal of user fees.Methods: A population cohort and representative health facilities were studied longitudinally over 3 years after the abolition of user fees. Quantitative and qualitative methods were used to obtain data. Parameters evaluated in relation to quality of care included availability of drugs and supplies and; health worker variables.Results: Different quality variables assessed showed that interventions that were put in place were able to maintain, or improve the technical quality of services. There were significant increases in utilization of services, average drug quantities and stock out days improved, and communities reported health workers to be hardworking, good and dedicated to their work to mention but a few. Communities were more appreciative of the services, though expectations were lower. However, health workers felt they were not adequately motivated given the increased workload.Conclusion: The levels of technical quality of care attained in a system with user fees can be maintained, or even improved without the fees through adoption of basic, sustainable system modifications that are within the reach of developing countries. However, a trade-off between residual perceptions of reduced service quality, and the welfare gains from removal of user fees should guide such a policy change. [ABSTRACT FROM AUTHOR]

Background: Reallocation of funding to respond the covid-19 pandemic, against a backdrop of longstanding underfunded health systems and high out of pocket expenditures for health, affected access to health services for households, especially those without social protection. These highlighted the urgency in curbing the impact of disruptions on progress towards Universal Health Coverage (UHC) goals. Strategic investments in Primary Health Care (PHC) can help spur the necessary momentum., Methods: Under the collaborative platform of the Harmonization for Health in Africa's Health Financing Technical Working Group; UNICEF Regional Office for East and Southern Africa and WHO Regional Office for Africa convened the first PHC financing forum for 21 countries across the Eastern and Southern Africa Region. The three-day forum engaged key health and financing decision makers in constructive dialogue to identify practical actions and policy changes needed to accelerate delivery of UHC through improvements in PHC financing mechanisms and arrangements. The forum was attended by over 130 senior policy makers and technicians from governments, United Nations agencies and nonstate actors drawn from within country, regional and affiliating headquarter institutions., Results: The Regional Forum engaged participants in meaningful, and constructive discussions. Five themes emerged (1) regular measurement and monitoring of PHC services and spending (2) increasing investments in PHC (3) enhancing efficiency, effectiveness, and equity of PHC spending, (4) ensuring an enabling environment to invest more and better in PHC, and (5) better partnerships for the realization of commitments. An outcome statement summarizing the main recommendations of the meeting was approved at the end of the forum, and action plans were developed by 14 government delegations to improve PHC financing within country-specific context and priorities., Conclusions and Recommendations: The aims of this meeting in augmenting the political will created through the Africa Leadership Meeting (ALM), by catalyzing technical direction for increased momentum for improved health financing across all African countries was achieved. Peer exchanges offered practical approaches countries can take to improve health financing in ways that are suited to regional context providing a channel for incremental improvements to health outcomes in the countries., (© 2024. The Author(s).)

Background: As the global strategies to fight the SARS-COV-2 infection (COVID-19) evolved, response strategies impacted the magnitude and distribution of health-related expenditures. Although the economic consequence of the COVID-19 pandemic has been dire, and its true scale is yet to be ascertained, one key component of the response is the management of infected persons which its cost has not been adequately examined, especially in Africa., Methods: To fill gaps in context-specific cost of treating COVID-19 patients, we adopted a health system's perspective and a bottom-up, point of care resource use data collection approach to estimate the cost of clinical management of COVID-19 infection in Ghana. The analysis was based on the national protocol for management of COVID-19 patients at the time, whether in public or private settings. No patients were enrolled into the study as it was entirely a protocol-based cost of illness analysis., Result: We found that resource use and average cost of treatment per COVID-19 case varied significantly by disease severity level and treatment setting. The average cost of treating COVID-19 patient in Ghana was estimated to be US$11,925 (GH¢68,929) from the perspective of the health system; ranging from US$282 (GH¢1629) for patients with mild/asymptomatic disease condition managed at home to about US$23,382 (GH¢135,149) for critically ill patients requiring sophisticated and specialised care in hospitals. The cost of treatment increased by some 20 folds once a patient moved from home management to the treatment centre. Overheard costs accounted for 63-71% of institutionalised care compared to only 6% for home-based care. The main cost drivers in overhead category in the institutionalised care were personal protective equipment (PPEs) and transportation, whilst investigations (COVID-19 testing) and staff time for follow-up were the main cost drivers for home-based care., Conclusion: Cost savings could be made by early detection and effective treatment of COVID-19 cases, preferably at home, before any chance of deterioration to the next worst form of the disease state, thereby freeing up more resources for other aspects of the fight against the pandemic. Policy makers in Ghana should thus make it a top priority to intensify the early detection and case management of COVID-19 infections., (© 2021. The Author(s).)

Background: Despite tremendous health workforce efforts which have resulted in increases in the density of physicians, nurses and midwives from 1.07 per 1000 population in 2005 to 2.65 per 1000 population in 2017, Ghana continues to face shortages of health workforce alongside inefficient distribution. The Ministry of Health and its agencies in Ghana used the Workload Indicators of Staffing Needs (WISN) approach to develop staffing norms and standards for all health facilities, which is being used as an operational planning tool for equitable health workforce distribution. Using the nationally agreed staffing norms and standards, the aim of this paper is to quantify the inequitable distribution of health workforce and the associated cost implications. It also reports on how the findings are being used to shape health workforce policy, planning and management., Methods: We conducted a health workforce gap analysis for all health facilities of the Ghana Health Service in 2018 in which we compared a nationally agreed evidence-based staffing standard with the prevailing staffing situation to identify need-based gaps and inequitable distribution. The cost of the prevailing staffing levels was also compared with the stipulated standard, and the staffing cost related to inequitable distribution was estimated., Results: It was found that the Ghana Health Service needed 105,440 health workers to meet its minimum staffing requirements as at May 2018 vis-à-vis its prevailing staff at post of 61,756 thereby leaving unfilled vacancies of 47,758 (a vacancy rate of 41%) albeit significant variations across geographical regions, levels of service and occupational groups. Of note, the crude equity index showed that in aggregate, the best-staffed region was 2.17 times better off than the worst-staffed region. The estimated cost (comprising basic salaries, market premium and other allowances paid from central government) of meeting the minimum staffing requirements was estimated to be GH¢2,358,346,472 (US$521,758,069) while the current cost of staff at post was GH¢1,424,331,400 (US$315,117,566.37), resulting in a net budgetary deficit of 57% (~ US$295.4 million) to meet the minimum requirement of staffing for primary and secondary health services. Whilst the prevailing staffing expenditure was generally below the required levels, an average of 28% (range 14-50%) across the levels of primary and secondary healthcare was spent on staff deemed to have been inequitably distributed, thus providing scope for rationalisation. We estimate that the net budgetary deficit of meeting the minimum staffing requirement could be drastically reduced by some 30% just by redistributing the inequitably distributed staff., Policy Implications: Efficiency gains could be made by redistributing the 14,142 staff deemed to be inequitably distributed, thereby narrowing the existing staffing gaps by 30% to 33,616, which could, in turn, be filled by leveraging synergistic strategy of task-sharing and/or new recruitments. The results of the analysis provided insights that have shaped and continue to influence important policy decisions in health workforce planning and management in the Ghana Health Service.

Background: The developments in global health, digital technology, and persistent health systems challenges, coupled with global commitments like attainment of universal health coverage, have elevated the role of health research in low- and middle-income countries. However, there is a need to strengthen health research governance and create a conducive environment that can promote ethics and research integrity and increase public trust in research., Objective: To assess whether the necessary structures are in place to ensure health research governance., Methods: Employing a cross-sectional survey, we collected data on research governance components from 35 Member States of the World Health Organization (WHO) African Region. Data were analysed using basic descriptive and comparative analysis., Results: Eighteen out of 35 countries had legislation to regulate the conduct of health research, while this was lacking in 12 countries. Some legislation was either grossly outdated or too limiting in scope, while some countries had multiple laws. Health research policies and strategies were in place in 16 and 15 countries, respectively, while research priority lists were available in 25 countries. Overlapping mandates of institutions responsible for health research partly explained the lack of strategic documents in some countries. The majority of countries had ethical committees performing a dual role of ethical and scientific review. Research partnership frameworks were available to varying degrees to govern both in-country and north-south research collaboration. Twenty-five countries had a focal point and unit within the ministries of health (MoH) to coordinate research., Conclusion: Governance structures must be adaptive to embrace new developments in science. Further, strong coordination is key to ensuring comprehensiveness and complementarity in both research development and generation of evidence. The majority of committees perform a dual role of ethics and scientific review, and these need to ensure representation of relevant expertise. Opportunities that accrue from collaborative research need to be seized through strong MoH leadership and clear partnership frameworks that guide negotiations.

Background: Health challenges and health systems set-ups differ, warranting contextualised healthcare interventions to move towards universal health coverage. As such, there is emphasis on generation of contextualized evidence to solve local challenges. However, weak research capacity and inadequate resources remain an impendiment to quality research in the African region. WHO African Region (WHO AFR) facilitated the adoption of a regional strategy for strengthening national health research systems (NHRS) in 2015. We assessed the progress in strengthening NHRS among the 47 member states of the WHO AFR., Methods: We employed a cross sectional survey design using a semi structured questionnaire. All the 47member states of WHO AFR were surveyed. We assessed performance against indicators of the regional research strategy, explored facilitating factors and barriers to strengthening NHRS. Using the research barometer, which is a metric developed for the WHO AFR we assessed the strength of NHRS of member states. Data were analysed in Excel Software to calculate barometer scores for NHRS function and sub-function. Thematic content was employed in analysing the qualitative data. Data for 2014 were compared to 2018 to assess progress., Results: WHO AFR member states have made significant progress in strengthening their NHRS. Some of the indicators have either attained or exceeded the 2025 targets. The average regional barometer score improved from 43% in 2014 to 61% in 2018. Significant improvements were registered in the governance of research for health (R4H); developing and sustaining research resources and producing and using research. Financing R4H improved only modestly. Among the constraints are the lengthy ethical clearance processes, weak research coordination mechanisms, weak enforcement of research laws and regulation, inadequate research infrastructure, limited resource mobilisation skills and donor dependence., Conclusion: There has been significant improvement in the NHRS of member states of the WHO AFRO since the last assessment in 2014. Improvement across the different objectives of the regional research strategy is however varied which compromises overall performance. The survey highlighted the areas with slow improvement that require a concerted effort. Furthermore, the study provides an opportunity for countries to share best practice in areas of excellence.

Background: In 2003 the Uganda Ministry of Health (MoH) introduced the District League Table (DLT) to track district performance. This review of the DLT is intended to add to the evidence base on Health Systems Performance Assessment (HSPA) globally, with emphasis on Low and Middle Income Countries (LMICs), and provide recommendations for adjustments to the current Ugandan reality., Methods: A normative HSPA framework was used to inform the development of a Key Informant Interview (KII) tool. Thirty Key Informants were interviewed, purposively selected from the Ugandan health system on the basis of having developed or used the DLT. KII data and information from published and grey literature on the Uganda health system was analyzed using deductive analysis., Results: Stakeholder involvement in the development of the DLT was limited, including MoH officials and development partners, and a few district technical managers. Uganda policy documents articulate a conceptually broad health system whereas the DLT focuses on a healthcare system. The complexity and dynamism of the Uganda health system was insufficiently acknowledged by the HSPA framework. Though DLT objectives and indicators were articulated, there was no conceptual reference model and lack of clarity on the constitutive dimensions. The DLT mechanisms for change were not explicit. The DLT compared markedly different districts and did not identify factors behind observed performance. Uganda lacks a designated institutional unit for the analysis and presentation of HSPA data, and there are challenges in data quality and range., Conclusions: The critique of the DLT using a normative model supported the development of recommendation for Uganda district HSPA and provides lessons for other LMICs. A similar approach can be used by researchers and policy makers elsewhere for the review and development of other frameworks. Adjustments in Uganda district HSPA should consider: wider stakeholder involvement with more district managers including political, administrative and technical; better anchoring within the national health system framework; integration of the notion of complexity in the design of the framework; and emphasis on facilitating district decision-making and learning. There is need to improve data quality and range and additional approaches for data analysis and presentation.

Background: Health sector and programme performance assessments provide a rich source of contextual data directly linked to implementation of programmes and can inform health policy dialogue, planning and resource allocation. In seeking to maximise this opportunity, there are challenges to overcome. A meeting convened by the World Health Organization African Region discussed the strengths, weaknesses and challenges to harmonising and standardising health sector and programme performance assessments, as well as use of evidence from such processes in decision making. This article synthesises the deliberations which emerged from the meeting. Discussing these in light of other literature we propose practical options to standardising health sector and programme performance assessment and improve realisation of using evidence in decision making., Discussion: Use of evidence generated from health sector and programme performance assessments into regular country processes of sectoral monitoring, dialogue and policy modification is crucial. However, this process faces several challenges. Identified challenges were categorised under several themes, namely the weak institutional capacities for monitoring and evaluation in reference to weak health information systems, a lack of tools and skills, and weak accountability mechanisms; desynchronised planning timeframes between programme and overall health sector strategies; inadequate time to undertake comprehensive and good quality performance assessment; weak mechanisms for following up on implementation of recommendations; lack of effective stakeholder participation; and divergent political aspirations., Conclusion: The question of what performance assessment is for in a country must be asked and answered clearly if the utility of these processes is to be realised. Standardising programme and sector reviews offers numerable opportunities that need to be maximised. Identified challenges need to be overcome through strengthened Ministry of Health leadership, effective stakeholder engagement and institutionalising follow-up mechanisms for agreed recommendations. In addition, health sector performance assessments need to be institutionalised as part of the accountability mechanism, and they must be planned for and funding secured within annual budget and medium term expenditure frameworks.

Background: Policy dialogue can be defined as an iterative process that involves a broad range of stakeholders discussing a particular issue with a concrete purpose in mind. Policy dialogue in health is increasingly being recognised by health stakeholders in developing countries, as an important process or mechanism for improving collaboration and harmonization in health and for developing comprehensive and evidence-based health sector strategies and plans. It is with this perspective in mind that Guinea, in 2013, started a policy dialogue process, engaging a plethora of actors to revise the country's national health policy and develop a new national health development plan (2015-2024). This study examines the coordination of the policy dialogue process in developing these key strategic governance documents of the Guinean health sector from the actors' perspective., Methods: A qualitative case study approach was undertaken, comprising of interviews with key stakeholders who participated in the policy dialogue process. A review of the literature informed the development of a conceptual framework and the data collection survey questionnaire. The results were analysed both inductively and deductively., Results: A total of 22 out of 32 individuals were interviewed. The results suggest both areas of strengths and weaknesses in the coordination of the policy dialogue process in Guinea. The aspects of good coordination observed were the iterative nature of the dialogue and the availability of neutral and well-experienced facilitators. Weak coordination was perceived through the unavailability of supporting documentation, time and financial constraints experienced during the dialogue process. The onset of the Ebola epidemic in Guinea impacted on coordination dynamics by causing a slowdown of its activities and then its virtual halt., Conclusions: The findings herein highlight the need for policy dialogue coordination structures to have the necessary administrative and institutional support to facilitate their effective functioning. The findings also point to the need for further research on the practical and operational aspects of national dialogue coordination structures to determine how to best strengthen their capacities.

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.

Background: Policy-making is a dynamic process involving the interplay of various factors. Power and its role are some of its core components. Though power exerts a profound role in policy-making, empirical evidence suggests that health policy analysis has paid only limited attention to the role of power, particularly in policy dialogues., Methods: This exploratory study, which used qualitative methods, had the main aim of learning about and understanding policy dialogues in five African countries and how power influences such processes. Data were collected using key informant interviews. An interview guide was developed with standardised questions and probes on the policy dialogues in each country. This paper utilises these data plus document review to understand how power was manifested during the policy dialogues. Reference is made to the Arts and Tatenhove conceptual framework on power dimensions to understand how power featured during the policy dialogues in African health contexts. Arts and Tatenhove conceptualise power in policy-making in relational, dispositional and structural layers., Results: Our study found that power was applied positively during the dialogues to prioritise agendas, fast-track processes, reorganise positions, focus attention on certain items and foster involvement of the community. Power was applied negatively during the dialogues, for example when position was used to control and shape dialogues, which limited innovation, and when knowledge power was used to influence decisions and the direction of the dialogues. Transitive power was used to challenge the government to think of implementation issues often forgotten during policy-making processes. Dispositional power was the most complex form of power expressed both overtly and covertly. Structural power was manifested socially, culturally, politically, legally and economically., Conclusions: This study shows that we need to be cognisant of the role of power during policy dialogues and put mechanisms in place to manage its influence. There is need for more research to determine how to channel power influence policy-making processes positively, for example through interactive policy dialogues.

Background: The Global Forum 2015 panel session dialogue entitled "From evidence to policy - thinking outside the box" was held on 26 August 2015 in the Philippines to debate why evidence was not fully translated into policy and practice and what could be done to increase its uptake. This paper reports the reasons and possible actions for increasing the uptake of evidence, and highlights the actions partners could take to increase the use of evidence in the African Region., Discussion: The Global Forum 2015 debate attributed African Region's low uptake of evidence to the big gap in incentives and interests between research for health researchers and public health policy-makers; limited appreciation on the side of researchers that public health decisions are based on multiple and complex considerations; perception among users that research evidence is not relevant to local contexts; absence of knowledge translation platforms; sub-optimal collaboration and engagement between industry and research institutions; lack of involvement of civil society organizations; lack of engagement of communities in the research process; failure to engage the media; limited awareness and debate in national and local parliaments on the importance of investing in research and innovation; and dearth of research and innovation parks in the African Region., Conclusion: The actions needed in the Region to increase the uptake of evidence in policy and practice include strengthening NHRS governance; bridging the motivation gap between researchers and health policy-makers; restoring trust between researchers and decision-makers; ensuring close and continuous intellectual intercourse among researchers, ministry of health policy-makers and technocrats during the life course of research projects or programmes; proactive collaboration between academia and industry; regular briefings of civil society, media, relevant parliamentary committees and development partners; development of vibrant knowledge translation platforms; development of action plans for implementing research recommendations, preferably in the context of the Sustainable Development Goals; and encouragement of competition on NHRS strengthening and research output and uptake among the countries using a barometer or scorecard to review their performance at various regional ministerial forums and taking into account the lessons learned from the MDG period.

Background: Policy processes that yield good outcomes are inherently complex, requiring interactions of stakeholders in problem identification, generation of political will and selection of practical solutions. To make policy processes rational, policy dialogues are increasingly being used as a policy-making tool. Despite their increasing use for policy-making in Africa, evidence is limited on how they have evolved and are being used on the continent or in low and middle income countries elsewhere., Methods: This was an exploratory study using qualitative methods. It utilised data related to policy dialogues for three specific policies and strategies to understand the interplay between policy dialogue and policy-making in Cabo Verde, Chad and Mali. The specific methods used to gather data were key informant interviews and document review. Data were analysed inductively and deductively using thematic content analysis., Results: Participation in the policy dialogues was inclusive, and in some instances bottom-up participatory approaches were used. The respondents felt that the execution of the policy dialogues had been seamless, and the few divergent views expressed often were resolved in a unanimous manner. The policies and strategies developed were seen by all stakeholders as relating to priority issues. Other specific process factors that contributed to the success of the dialogues included the use of innovative approaches, good facilitation, availability of resources for the dialogues, good communication, and consideration of the different opinions. Among the barriers were contextual issues, delays in decision-making and conflicting coordination roles and mandates., Conclusions: Policy dialogues have proved to be an effective tool in health sector management and could be a crucial component of the governance dynamics of the sector. The policy dialogue process needs to be institutionalised for continuity and maintenance of institutional intelligence. Other essential influencing factors include building capacity for coordination and facilitation of policy dialogues, provision of sustainable financing for execution of the dialogues, use of inclusive and bottom-up approaches, and timely provision of reliable evidence. Ensuring continued participation of all the actors necessitates innovation to allow dialogue outside the formal frameworks and spaces that should feed into the formal dialogue processes.

Background: Countries in the World Health Organization African Region have witnessed an increase in global health initiatives in the recent past. Although these have provided opportunities for expanding coverage of health interventions; their poor alignment with the countries' priorities and weak coordination, are among the challenges that have affected their impact. A well-coordinated health policy dialogue provides an opportunity to address these challenges, but calls for common understanding among stakeholders of what policy dialogue entails. This paper seeks to assess stakeholders' understanding and perceived importance of health policy dialogue and of policy dialogue coordination., Methods: This was a cross-sectional descriptive study using qualitative methods. Interviews were conducted with 90 key informants from the national and sub-national levels in Lusophone Cabo Verde, Francophone Chad, Guinea and Togo, and Anglophone Liberia using an open-ended interview guide. The interviews were transcribed verbatim, coded and then put through inductive thematic content analysis using QRS software Version 10., Results: There were variations in the definition of policy dialogue that were not necessarily linked to the linguistic leaning of respondents' countries or whether the dialogue took place at the national or sub-national level. The definitions were grouped into five categories based on whether they had an outcome, operational, process, forum or platform, or interactive and evidence-sharing orientation. The stakeholders highlighted multiple benefits of policy dialogue including ensuring stakeholder participation, improving stakeholder harmonisation and alignment, supporting implementation of health policies, fostering continued institutional learning, providing a guiding framework and facilitating stakeholder analysis., Conclusion: Policy dialogue offers the opportunity to improve stakeholder participation in policy development and promote aid effectiveness. However, conceptual clarity is needed to ensure pursuance of common objectives. While it is clear that stakeholder involvement is an important component of policy dialogue, numbers must be manageable for meaningful dialogue. Ownership and coordination of the policy dialogue are important aspects of the process, and building the institutional capacity of the ministry of health requires a comprehensive approach as opposed to strengthening selected departments within it. Likewise, capacity for policy dialogue needs to be built at the sub-national level, alongside improving the bottom-up approach in policy processes.

Background: In the last decade participatory approaches have gained prominence in policy-making, becoming the focus of good policy-making processes. Policy dialogue is recognised as an important aspect of policy-making among several interactive and innovative policy-making models applied in different contexts and sectors. Recently there has been emphasis on the quality of policy dialogue in terms of how it should be conducted to attain participation and inclusiveness. However, there is paucity of evidence on how the context influences policy dialogue, particularly participation of stakeholders. Liberia's context, which is characterised as post-war, highly donor dependent and in recovery from the recent catastrophic Ebola outbreak, provides an opportunity to understand the influence of context on policy dialogue., Methods: This was an exploratory study using qualitative methods. Key informant interviews were conducted using an interview guide. A total of 16 interviews were conducted, 12 at the national level and 4 at the sub national level. Data were analysed using inductive thematic content analysis., Results: The respondents felt that the dialogues were a success and involved important stakeholders; however, there were concerns about the improper methodology and facilitation used to conduct them. Opinions among the respondents about the process of generating and selecting the themes for the dialogues were extremely divergent. Both before and during the Ebola outbreak, the context was instrumental in shaping the dialogues according to the issue of focus, requirements for participation and the decisions to be made. Policy dialogues have become a platform for policy discussions and decisions in Liberia. It is a process that is well recognised and appreciated and is highly attributed to the success of the negotiations during the Ebola outbreak., Conclusions: To sustain and strengthen policy dialogues in future, there needs to be proper information sharing through diverse forums and avenues, stakeholders' empowerment and competent facilitation. These will ensure that the process is credible and legitimate.

Background: Harmonisation is a key principle of the Paris Declaration. The Universal Health Coverage (UHC) Partnership, an initiative of the European Union, the Government of Luxembourg and the World Health Organization, supported health policy dialogues between 2012 and 2015 in identified countries in the WHO African Region. The UHC Partnership has amongst its key objectives to strengthen national health policy development. In Guinea and Chad, policy dialogue focused on elaborating the national health plan and other key documents. This study is an analytical reflection inspired by realist evaluative approaches to understand whether policy dialogue led to improved harmonisation amongst health actors in Guinea and Chad, and if so, how and why., Methods: Interviews were conducted in Guinea and Chad with key informants at the national and sub-national government levels, civil society, and development partners. A review of relevant policy documents and reports was added to data collection to construct a full picture of the policy dialogue process. Context-mechanism-outcome configurations were used as the realist framework to guide the analysis on how participants' understanding of what policy dialogue was and the way the policy dialogue process unfolded led to improved harmonisation., Results: Improved harmonisation as a result of policy dialogue was perceived to be stronger in Guinea than in Chad. While in both countries the participants held a shared view of what policy dialogue was and what it could achieve, and both policy dialogue processes were considered to be well implemented (i.e., well-facilitated, evidence-based, participatory, and consisted of recurring meetings and activities), certain contextual factors in Chad tempered the view of harmonisation as having improved. These were the pre-existence of dialogic policy processes that had exposed the actors to the potential that policy dialogue could have; a focus on elaborating provincial level strategies, which gave the sense that the process was more bottom-up; and the perception that there were acute resource constraints, which conditioned partners' interactions., Conclusions: Policy dialogue improves harmonisation in terms of fostering information exchange amongst partners; however, it does not appear to influence the operational procedures of the actors. This has implications for aid effectiveness.

Background: Majority of the countries in the World Health Organization (WHO) African Region are not on track to achieve the health-related Millennium Development Goals, yet even more ambitious Sustainable Development Goals (SDGs), including SDG 3 on heath, have been adopted. This paper highlights the challenges - amplified by the recent Ebola virus disease (EVD) outbreak in West Africa - that require WHO and other partners' dialogue in support of the countries, and debate on how WHO can leverage the existing space and place to foster health development dialogues in the Region., Discussion: To realise SDG 3 on ensuring healthy lives and promoting well-being for all at all ages, the African Region needs to tackle the persistent weaknesses in its health systems, systems that address the social determinants of health and national health research systems. The performance of the third item is crucial for the development and innovation of systems, products and tools for promoting, maintaining and restoring health in an equitable manner. Under its new leadership, the WHO Regional Office for Africa is transforming itself to galvanise existing partnerships, as well as forging new ones, with a view to accelerating the provision of timely and quality support to the countries in pursuit of SDG 3. WHO in the African Region engages in dialogues with various stakeholders in the process of health development. The EVD outbreak in West Africa accentuated the necessity for optimally exploiting currently available space and place for health development discourse. There is urgent need for the WHO Regional Office for Africa to fully leverage the space and place arenas of the World Health Assembly, WHO Regional Committee for Africa, African Union, Regional economic communities, Harmonization for Health in Africa, United Nations Economic Commission for Africa, African Development Bank, professional associations, and WHO African Health Forum, when it is created, for dialogues to mobilise the required resources to give the African Region the thrust it needs to attain SDG 3., Conclusions: The pursuit of SDG 3 amidst multiple challenges related to political leadership and governance, weak health systems, sub-optimal systems for addressing the socioeconomic determinants of health, and weak national health research systems calls for optimum use of all the space and place available for regional health development dialogues to supplement Member States' efforts.

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.

Background: This paper has three objectives: to review the health development landscape in the World Health Organization African Region, to discuss the role of health policy dialogue in improving harmonisation and alignment to national health policies and strategic plans, and to provide an analytical view of the critical factors in realising a good outcome from a health policy dialogue process., Discussion: Strengthening policy dialogue to support the development and implementation of robust and comprehensive national health policies and plans, as well as to improve aid effectiveness, is seen as a strategic entry point to improving health sector results. However, unbalanced power relations, the lack of contextualised and relevant evidence, the diverse interests of the actors involved, and the lack of conceptual clarity on what policy dialogue entails impact the outcomes of a policy dialogue process. The critical factors for a successful policy dialogue have been identified as adequate preparation; secured time and resources to facilitate an open, inclusive and informed discussion among the stakeholders; and stakeholders' monitoring and assessment of the dialogue's activities for continued learning. Peculiarities of low income countries pose a challenge to their policy dialogue processes, including the chaotic-policy making processes, the varied capacity of the actors and donor dependence., Conclusion: Policy dialogue needs to be appreciated as a complex and iterative process that spans the whole process of policy-making, implementation, review and monitoring, and subsequent policy revisions. The existence of the critical factors for a successful policy dialogue process needs to be ensured whilst paying special attention to the peculiarities of low income countries and potential power relations, and mitigating the possible negative consequences. There is need to be cognisant of the varied capacities and interests of stakeholders and the need for capacity building, and to put in place mechanisms to manage conflict of interest. The likelihood of a favourable outcome from a policy dialogue process will depend on the characteristics of the issue under consideration and whether it is contested or not, and the policy dialogue process needs to be tailored accordingly.

Background: Worldwide, a total of 6.282 million deaths occurred among children aged less than 5 years in 2013. About 47.4 % of those were borne by the 47 Member States of the World Health Organization (WHO) African Region. Sadly, even as we approach the end date for the 2015 Millennium Development Goals (MDGs), only eight African countries are on track to achieve the MDG 4 target 4A of reducing under-five mortality by two thirds between 1990 and 2015. The post-2015 Sustainable Development Goal (SDG) 3 target is "by 2030, end preventable deaths of new-borns and children under 5 years of age". There is urgent need for increased advocacy among governments, the private sector and development partners to provide the resources needed to build resilient national health systems to deliver an integrated package of people-centred interventions to end preventable child morbidity and mortality and other structures to address all the basic needs for a healthy population. The specific objective of this study was to estimate expected/future productivity losses from child deaths in the WHO African Region in 2013 for use in advocacy for increased investments in child health services and other basic services that address children's welfare., Methods: A cost-of-illness method was used to estimate future non-health GDP losses related to child deaths. Future non-health GDP losses were discounted at 3 %. The analysis was undertaken with the countries categorized under three income groups: Group 1 consisted of nine high and upper middle income countries, Group 2 of 13 lower middle income countries, and Group 3 of 25 low income countries. One-way sensitivity analysis at 5 % and 10 % discount rates assessed the impact of the expected non-health GDP loss., Results: The discounted value of future non-health GDP loss due to the deaths of children under 5 years old in 2013 will be in the order of Int$ 150.3 billion. Approximately 27.3 % of the loss will be borne by Group 1 countries, 47.1 % by Group 2 and 25.7 % by Group 3. The average non-health GDP lost per child death will be Int$ 174 310 for Group 1, Int$ 57 584 for Group 2 and Int$ 25 508 for Group 3., Conclusions: It is estimated that the African Region will incur a loss of approximately 6 % of its non-health GDP from the future years of life lost among the 2 976 000 child deaths that occurred in 2013. Therefore, countries and development partners should in solidarity sustainably provide the resources essential to build resilient national health systems and systems to address the determinants of health and meet the other basic needs such as for clothing, education, food, shelter, sanitation and clean water to end preventable child morbidity and mortality.

Background: Several countries in Sub Saharan Africa have abolished user fees for health care but the extent to which such a policy decision is guided by evidence needs further exploration. We explored the barriers and facilitating factors to uptake of evidence in the process of user fee abolition in Uganda and how the context and stakeholders involved shaped the uptake of evidence. This study builds on previous work in Uganda that led to the development of a middle range theory (MRT) outlining the main facilitating factors for knowledge translation (KT). Application of the MRT to the case of abolition of user fees contributes to its refining., Methods: Employing a theory-driven inquiry and case study approach given the need for in-depth investigation, we reviewed documents and conducted interviews with 32 purposefully selected key informants. We assessed whether evidence was available, had or had not been considered in policy development and the reasons why and; assessed how the actors and the context shaped the uptake of evidence., Results: Symbolic, conceptual and instrumental uses of evidence were manifest. Different actors were influenced by different types of evidence. While technocrats in the ministry of health (MoH) relied on formal research, politicians relied on community complaints. The capacity of the MoH to lead the KT process was weak and the partnerships for KT were informal. The political window and alignment of the evidence with overall government discourse enhanced uptake of evidence. Stakeholders were divided, seemed to be polarized for various reasons and had varying levels of support and influence impacting the uptake of evidence., Conclusion: Evidence will be taken up in policy development in instances where the MoH leads the KT process, there are partnerships for KT in place, and the overall government policy and the political situation can be expected to play a role. Different actors will be influenced by different types of evidence and their level of support and influence will impact the uptake of evidence. In addition, the extent to which a policy issue is contested and, whether stakeholders share similar opinions and preferences will impact the uptake of evidence.

Background: Uganda changed its malaria treatment policy in response to evidence of resistance to commonly used antimalarials. The use of evidence in policy development--also referred to as knowledge translation (KT)--is crucial, especially in resource-limited settings. However, KT processes occur amidst a complex web of stakeholder interactions. Stakeholder involvement in evidence generation and in KT activities is essential. In the present study, we explored how stakeholders impacted the uptake of evidence in the malaria treatment policy change in Uganda., Methods: We employed a qualitative case study methodology involving interviews with key informants and review of documents. A timeline of events was developed, which guided the purposive sampling of respondents and identification of relevant documents. Data were analysed using inductive content analysis techniques., Results: Stakeholders played multiple roles in evidence uptake in the malaria treatment policy change. Donors, the Ministry of Health (MoH), service providers, and researchers engaged in the role of evidence generation. The MoH, parliamentarians, and opinion leaders at the national and local levels engaged in dissemination of evidence. The donors, MoH, researchers, and service providers engaged in the uptake of evidence in policy development and implementation. Stakeholders exerted varying levels of support and influence for different reasons. It is noteworthy that all of the influential stakeholders were divided regarding the best antimalarial alternative to adopt., Conclusion: Our results showed a diverse group of stakeholders who played multiple roles, with varying levels of support and influence on the uptake of evidence in the malaria treatment policy change. For a given KT processes, mapping the relevant stakeholders and devising mechanism for their engagement and for how to resolve conflicts of interest and disagreements a priori will enhance uptake of evidence in policy development.

Background: Although increasing attention is being paid to knowledge translation (KT), research findings are not being utilized to the desired extent. The present study explores the role of evidence, barriers, and factors facilitating the uptake of evidence in the change in malaria treatment policy in Uganda, building on previous work in Uganda that led to the development of a middle range theory (MRT) outlining the main facilitatory factors for KT. Application of the MRT to a health policy case will contribute to refining it., Methods: Using a case study approach and mixed methods, perceptions of respondents on whether evidence was available, had been considered and barriers and facilitatory factors to the uptake of evidence were explored. In addition, the respondents' rating of the degree of consistency between the policy decision and available evidence was assessed. Data collection methods included key informant interviews and document review. Qualitative data were analysed using content thematic analysis, whereas quantitative data were analysed using Excel spreadsheets. The two data sets were eventually triangulated., Results: Evidence was used to change the malaria treatment policy, though the consistency between evidence and policy decisions varied along the policy development cycle. The availability of high-quality and contextualized evidence, including effective dissemination, Ministry of Health institutional capacity to lead the KT process, intervention of the WHO and a regional professional network, the existence of partnerships for KT with mutual trust and availability of funding, tools, and inputs to implement evidence, were the most important facilitatory factors that enhanced the uptake of evidence. Among the barriers that had to be overcome were resistance from implementers, the health system capacity to implement evidence, and financial sustainability., Conclusion: The results agree with facilitatory factors identified in the earlier developed MRT, though additional factors emerged. These results refine the earlier MRT stating that high-quality and contextualized evidence will be taken up in policies, leading to evidence-informed policies when the MoH leads the KT process, partnerships are in place for KT, the WHO and regional professional bodies play a role, and funding, tools, and required inputs for implementing evidence are available.

Background: The study aimed at developing a set of attributes for a 'good' health system performance assessment (HSPA) framework from literature and experiences in different contexts and using the attributes for a structured approach to lesson learning for low-income countries (LICs)., Methods: Literature review to identify relevant attributes for a HSPA framework; attribute validation for LICs in general, and for Uganda in particular, via a high-level Ugandan expert group; and, finally, review of a selection of existing HSPA frameworks using these attributes., Results: Literature review yielded six key attributes for a HSPA framework: an inclusive development process; its embedding in the health system's conceptual model; its relation to the prevailing policy and organizational set-up and societal context; the presence of a concrete purpose, constitutive dimensions and indicators; an adequate institutional set-up; and, its capacity to provide mechanisms for eliciting change in the health system. The expert group contextualized these attributes and added one on the adaptability of the framework.Lessons learnt from the review of a selection of HSPA frameworks using the attributes include: it is possible and beneficial to involve a range of stakeholders during the process of development of a framework; it is important to make HSPA frameworks explicit; policy context can be effectively reflected in the framework; there are marked differences between the structure and content of frameworks in high-income countries, and low- and middle-income countries; champions can contribute to put HSPA high on the agenda; and mechanisms for eliciting change in the health system should be developed alongside the framework., Conclusion: It is possible for LICs to learn from literature and the experience of HSPA in other contexts, including HICs. In this study a structured approach to lesson learning included the development of a list of attributes for a 'good' HSPA framework. The attributes thus derived can be utilized by LICs like Uganda seeking to develop/adjust their HSPA frameworks as guidelines or a check list, while taking due consideration of the specific context. The review of frameworks from varied contexts, highlighted varied experiences which provide lessons for LICs.

Background: Stakeholder roles in the application of evidence are influenced by context, the nature of the evidence, the policy development process, and stakeholder interactions. Past research has highlighted the role of stakeholders in knowledge translation (KT) without paying adequate attention to the peculiarities of low-income countries. Here we identify the roles, relations, and interactions among the key stakeholders involved in KT in Uganda and the challenges that they face., Methods: This study employed qualitative approaches to examine the roles of and links among various stakeholders in KT. In-depth interviews were conducted with 21 key informants and focused on the key actors in KT, their perceived roles, and challenges., Results: Major stakeholders included civil society organizations with perceived roles of advocacy, community mobilization, and implementation. These stakeholders may ignore unconvincing evidence. The community's role was perceived as advocacy and participation in setting research priorities. The key role of the media was perceived as knowledge dissemination, but respondents noted that the media may misrepresent evidence if it is received in a poorly packaged form. The perceived roles of policy makers were evidence uptake, establishing platforms for KT and stewardship; negative roles included ignoring or even misrepresenting evidence that is not in their favor. The roles of parliamentarians were perceived as advocacy and community mobilization, but they were noted to pursue objectives that may not be supported by the evidence. The researchers' main role was defined as evidence generation, but focusing disproportionately on academic interests was cited as a concern. The donors' main role was defined as funding research and KT, but respondents were concerned about the local relevance of donor-supported research. Respondents reported that links among stakeholders were weak due to the absence of institutionalized, inclusive platforms. Challenges facing the stakeholders in the process of KT were identified., Conclusions: Our investigation revealed the need to consider the roles that various stakeholders are best placed to play. Links and necessary platforms must be put in place to achieve synergy in KT. Relevant capacities need to be built to overcome the challenges faced by the various stakeholders.

Background: The objectives of this study were to assess the patterns of treatment seeking behaviour for children under five with malaria; and to examine the statistical relationship between out-of-pocket expenditure (OOP) on malaria treatment for under-fives and source of treatment, place of residence, education and wealth characteristics of Uganda households. OOP expenditure on health care is now a development concern due to its negative effect on households' ability to finance consumption of other basic needs., Methods: The 2009 Uganda Malaria Indicator Survey was the source of data on treatment seeking behaviour for under-five children with malaria, and patterns and levels of OOP expenditure for malaria treatment. Binomial logit and Log-lin regression models were estimated. In logit model the dependent variable was a dummy (1=incurred some OOP, 0=none incurred) and independent variables were wealth quintiles, rural versus urban, place of treatment, education level, sub-region, and normal duty disruption. The dependent variable in Log-lin model was natural logarithm of OOP and the independent variables were the same as mentioned above., Results: Five key descriptive analysis findings emerge. First, malaria is quite prevalent at 44.7% among children below the age of five. Second, a significant proportion seeks treatment (81.8%). Third, private providers are the preferred option for the under-fives for the treatment of malaria. Fourth, the majority pay about 70.9% for either consultation, medicines, transport or hospitalization but the biggest percent of those who pay, do so for medicines (54.0%). Fifth, hospitalization is the most expensive at an average expenditure of US$7.6 per child, even though only 2.9% of those that seek treatment are hospitalized.The binomial logit model slope coefficients for the variables richest wealth quintile, Private facility as first source of treatment, and sub-regions Central 2, East central, Mid-eastern, Mid-western, and Normal duties disrupted were positive and statistically significant at 99% level of confidence. On the other hand, the Log-lin model slope coefficients for Traditional healer, Sought treatment from one source, Primary educational level, North East, Mid Northern and West Nile variables had a negative sign and were statistically significant at 95% level of confidence., Conclusion: The fact that OOP expenditure is still prevalent and private provider is the preferred choice, increasing public provision may not be the sole answer. Plans to improve malaria treatment should explicitly incorporate efforts to protect households from high OOP expenditures. This calls for provision of subsidies to enable the private sector to reduce prices, regulation of prices of malaria medicines, and reduction/removal of import duties on such medicines.

Background: A guideline contains processes and procedures intended to guide health service delivery. However, the presence of guidelines may not guarantee their implementation, which may be a result of weaknesses in the development process. This study was undertaken to describe the processes of developing health planning, services management, and clinical guidelines within the health sector in Uganda, with the goal of understanding how these processes facilitate or abate the utility of guidelines., Methods: Qualitative and quantitative research methods were used to collect and analyze data. Data collection was undertaken at the levels of the central Ministry of Health, the district, and service delivery. Qualitative methods included review of documents, observations, and key informant interviews, as well as quantitative aspects included counting guidelines. Quantitative data were analyzed with Microsoft Excel, and qualitative data were analyzed using deductive content thematic analysis., Results: There were 137 guidelines in the health sector, with programs related to Millennium Development Goals having the highest number (n = 83). The impetus for guideline development was stated in 78% of cases. Several guidelines duplicated content, and some conflicted with each other. The level of consultation varied, and some guidelines did not consider government-wide policies and circumstances at the service delivery level. Booklets were the main format of presentation, which was not tailored to the service delivery level. There was no framework for systematic dissemination, and target users were defined broadly in most cases. Over 60% of guidelines available at the central level were not available at the service delivery level, but there were good examples in isolated cases. There was no framework for systematic monitoring of use, evaluation, and review of guidelines. Suboptimal performance of the supervision framework that would encourage the use of guidelines, assess their utilization, and provide feedback was noted., Conclusions: Guideline effectiveness is compromised by the development process. To ensure the production of high-quality guidelines, efforts must be employed at the country and regional levels. The regional level can facilitate pooling resources and expertise in knowledge generation, methodology development, guideline repositories, and capacity building. Countries should establish and enforce systems and guidance on guideline development.

Background: The National Health Policy 2000 - 2009 and Health sector strategic plans I & II emphasized that Primary Health Care (PHC) would be the main strategy for national development and would be operationalized through provision of the minimum health care package. Commitment was to spend an increasing proportion of the health budget for the provision of the basic minimum package of health services which was interpreted to mean increasing spending at health centre level. This analysis was undertaken to gain a better understanding of changes in the way recurrent funding is allocated in the health sector in Uganda and to what extent it has been in line with agreed policy priorities., Methods: Government recurrent wage and non-wage expenditures - based on annual releases by the Uganda Ministry of Finance, Planning and Economic Development were compiled for the period 1997/1998 to financial year 2007/2008. Additional data was obtained from a series of Ministry of Health annual health sector reports as well as other reports. Data was verified by key government officials in Ministry of Finance, Planning and Economic Development and Ministry of Health. Analysis of expenditures was done at sector level, by the different levels in the health care system and the different levels of care., Results: There was a pronounced increase in the amount of funds released for recurrent expenditure over the review period fueled mainly by increases in the wage component. PHC services showed the greatest increase, increasing more than 70 times in ten years. At hospital level, expenditures remained fairly constant for the last 10 years with a slight reduction in the wage component., Conclusion: The policy aspiration of increasing spending on PHC was attained but key aspects that would facilitate its realization were not addressed. At any given level of funding for the health sector, there is need to work out an optimal balance in investment in the different inputs to ensure efficiency in health spending. Equally important is the balance in investment between hospitals and health centers. There is a need to look comprehensively at what it takes to provide PHC services and invest accordingly.