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Background: The COVID-19 pandemic has significantly impacted frontline health workers. However, a neglected dimension of this discourse was the extent to which the pandemic impacted frontline healthcare workers providing non-communicable diseases (NCDs) care. This study aims to understand the experiences of healthcare workers with no prior exposure to pandemics who provided care to people living with NCDs (PLWNCDs)., Methods: A qualitative study design was employed, using a face-to-face in-depth interviews. Interviews were conducted in primary healthcare facilities in three administrative regions of Ghana, representing the Northern, Southern and Middle Belts. Only frontline health workers with roles in providing care for PLWNCDs were included. Purposive snowballing and convenience sampling methods were employed to select frontline health workers. An open-ended interview guide was used to facilitate data collection, and thematic content analysis was used to analyse the data., Results: A total of 47 frontline health workers were interviewed. Overall, these workers experienced diverse patient-driven and organisational challenges. Patient-level challenges included a decline in healthcare utilisation, non-adherence to treatment, a lack of continuity, fear and stigma. At the organisational levels, there was a lack of medical logistics, increased infection of workers and absenteeism, increased workload and burnout, limited motivational packages and inadequate guidelines and protocols. Workers coped and responded to the pandemic by postponing reviews and consultations, reducing inpatient and outpatient visits, changing their prescription practices, using teleconsultation and moving to long-shift systems., Conclusion: This study has brought to the fore the experiences that adversely affected frontline health workers and, in many ways, affected the care provided to PLWNCDs. Policymakers and health managers should take these experiences into account in plans to mitigate the impact of future pandemics., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Community health workers (CHWs) constitute the majority of primary healthcare (PHC) workers in Nigeria, yet little is understood about their motivations or the most effective interventions to meet their needs to ensure quality health coverage across the country. We aimed to identify factors that would motivate CHWs for quality service delivery., Methods: A discrete-choice experiment was conducted among 300 CHWs across 44 PHC facilities in the Federal Capital Territory, Abuja Nigeria. Based on the literature review and qualitative research, five attributes, namely: salary, educational opportunities, career progression and in-service training, housing and transportation, were included in the experiment. CHWs were presented with 12 unlabelled choice sets, using tablet devices, and asked to choose which of two hypothetical jobs they would accept if offered to them, or whether they would take neither job. Mixed multinomial logistic models were used to estimate stated preferences for the attributes and the likely uptake of jobs under different policy packages was simulated., Results: About 70% of the respondents were women and 39% worked as volunteers. Jobs that offered career progression were the strongest motivators among the formally employed CHWs (β=0.33) while the 'opportunity to convert from CHW to another cadre of health workers, such as nursing' was the most important motivator among the volunteers' CHWs (β=0.53). CHWs also strongly preferred jobs that would offer educational opportunities, including scholarship (β=0.31) and provision of transport allowances (β=0.26). Policy scenario modelling predicted combined educational opportunities, career progression opportunities and an additional 10% of salary as incentives was the employment package that would be most appealing to CHWs., Conclusion: CHWs are motivated by a mix of non-financial and financial incentives. Policy interventions that would improve motivation should be adequate to address various contexts facing different CHWs and be flexible enough to meet their differing needs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Ethiopia has recently revitalised its health extension programme (HEP) to address the rising burden of non-communicable diseases (NCDs). We examined the effects of existing essential HEP services on the uptake of NCD preventive services., Methods: We applied a mixed-effect non-linear model with a logit link function to identify factors associated with a community resident's probability of receiving NCD prevention services through the HEP. The data were drawn from the Ethiopian HEP assessment Survey conducted in all regions. The analysis included 9680 community residents, 261 health extension workers (HEWs), 153 health posts, 119 health centres, 55 districts and 9 regions, which we combined hierarchically into a single database., Results: In the 12 months before the survey, 22% of the sample population reported receiving NCD preventive service at least once. The probability of receiving NCD prevention service increased by up to 25% (OR=1.25, CI 1.01 to 1.53) if health centres routinely gathered NCD data from health posts and by up to 48% (OR=.48, CI 1.24 to 1.78) if they provided general (ie, non-NCD specific) training to HEWs. NCD preventive service uptake also increased if the HEW held level IV qualification (OR=1.32, CI 1.06 to 1.65) and lived in the community (OR=1.24, CI 1.03 to 1.49). Conversely, if facilities delayed general performance reviews of HEWs by a month, uptake of NCD prevention services decreased by 6% (OR=0.94, CI 0.91 to 0.97). We observed that better HIV/AIDS programme performance was associated with a lower uptake of NCD preventive services (OR=0.15, CI 0.03 to 0.85)., Conclusion: Despite efforts to improve NCD services through the HEP, the coverage remains limited. A strong HEP is good for the uptake of NCD preventive services. However, integration requires a careful balance, so that the success already recorded for some existing programmes is not lost., Competing Interests: Competing interests: AGT, DP, RJ and YK declare no competing interests. SA is Editor in Chief of BMJ Global Health. AT and FWF are employees of MERQ Consultancy PLC, however, this does not alter our adherence to BMJ Global Health policies on sharing data and materials., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Objective: To understand how, and under what circumstances community participation in water and sanitation interventions impacts the availability of safe water and sanitation, a change in health status or behaviour and the longevity of water, sanitation and hygiene (WASH) resources and services., Design: Realist review., Data Sources: PubMed, Web of Science and Scopus databases were used to identify papers from low-income and middle-income countries from 2010 to 2020., Eligibility Criteria for Selecting Studies: Criteria were developed for papers to be included. The contribution of each paper was assessed based on its relevance and rigour (eg, can it contribute to context, mechanism or outcome, and is the method used to generate that information credible)., Analysis: Inductive and deductive coding was used to generate context-mechanism-outcome configurations., Results: 73 studies conducted in 29 countries were included. We identified five mechanisms that explained the availability, change and longevity outcomes: (1) accountability (policies and procedures to hold communities responsible for their actions and outcomes of an intervention), (2) diffusion (spread of an idea or behaviour by innovators over time through communication among members of a community), (3) market (the interplay between demand and supply of a WASH service or resource), (4) ownership (a sense of possession and control of the WASH service or resource) and (5) shame (a feeling of disgust in one's behaviour or actions). Contextual elements identified included community leadership and communication, technical skills and knowledge, resource access and dependency, committee activity such as the rules and management plans, location and the level of community participation., Conclusions: The findings highlight five key mechanisms impacted by 19 contextual factors that explain the outcomes of community water and sanitation interventions. Policymakers, programme implementers and institutions should consider community dynamics, location, resources, committee activity and practices and nature of community participation, before introducing community water and sanitation interventions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Though multidisciplinary research networks support the practice and effectiveness of continuous quality improvement (CQI) programmes, their characteristics and development are poorly understood. In this study, we examine publication outputs from a research network in Australian Indigenous primary healthcare (PHC) to assess to what extent the research network changed over time., Setting: Australian CQI research network in Indigenous PHC from 2002 to 2019., Participants: Authors from peer-reviewed journal articles and books published by the network., Design: Coauthor networks across four phases of the network (2002-2004; 2005-2009; 2010-2014; 2015-2019) were constructed based on author affiliations and examined using social network analysis methods. Descriptive characteristics included organisation types, Indigenous representation, gender, student authorship and thematic research trends., Results: We identified 128 publications written by 308 individual authors from 79 different organisations. Publications increased in number and diversity over each funding phase. During the final phase, publication outputs accelerated for organisations, students, project officers, Indigenous and female authors. Over time there was also a shift in research themes to encompass new clinical areas and social, environmental or behavioural determinants of health. Average degree (8.1), clustering (0.81) and diameter (3) indicated a well-connected network, with a core-periphery structure in each phase (p≤0.03) rather than a single central organisation (degree centralisation=0.55-0.65). Academic organisations dominated the core structure in all funding phases., Conclusion: Collaboration in publications increased with network consolidation and expansion. Increased productivity was associated with increased authorship diversity and a decentralised network, suggesting these may be important factors in enhancing research impact and advancing the knowledge and practice of CQI in PHC. Publication diversity and growth occurred mainly in the fourth phase, suggesting long-term relationship building among diverse partners is required to facilitate participatory research in CQI. Despite improvements, further work is needed to address inequities in female authorship and Indigenous authorship., Competing Interests: Competing interests: The authors declare that this research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Indigenous communities worldwide are leading calls for all research involving Indigenous people to be underpinned by values and principles articulated by them. Many researchers are explicitly adopting these principles to guide what, where, how and when research is undertaken with Indigenous people. With critical reflection to support the implementation of such principles largely absent from published literature, this paper explores both the implementation of, and the outcomes from a set of guiding principles used in a large-scale Australian research collaboration to improve Indigenous health., Methods: In this inductive qualitative study, we adopted a principles-focused evaluation approach. Based on interviews with 35 actors in the collaboration and a review of project documents, we generated themes that were then iteratively discussed, refined and categorised into (1) 'strategies'-activities by which implementation of our guiding principles were recognised; (2) 'outcomes'-results seen from implementing the principles and (3) 'conditions'-aspects of the context that facilitated and constrained implementation of the principles., Results: Respondents found it difficult to articulate how the guiding principles were actually implemented, and frequently referred to them as part of the fabric of the collaboration. They viewed the set of principles as mutually reinforcing, and as providing a rudder for navigating complexity and conflict. Implementation of the principles occurred through five strategies-honouring the principles; being dynamic and adaptable; sharing and dispersing leadership; collaborating purposefully and adopting a culture of mutual learning. Outcomes included increased Indigenous leadership and participation; the ability to attract principled and values-driven researchers and stakeholders, and the development of trusting and respectful relationships. The conditions that facilitated the implementation of the principles were collaborating over time; an increasing number of Indigenous researchers and taking an 'innovation platform' approach., Conclusion: Our findings show that principles guiding collaborations are valuable in providing a focus, direction and a way of working together when they are collaboratively developed, hold genuine meaning for all members and are implemented within a culture of continuous critical reflection, learning and adaptation, with ongoing reinterpretation of the principles over time., Competing Interests: Competing interests: The authors declare that this research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. SA is the Editor in Chief of BMJ Global Health, but was not involved in the evaluation or peer-review process of this article., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Interprofessional interaction is intrinsic to health service delivery and forms the basis of task-shifting and task-sharing policies to address human resources for health challenges. But while interprofessional interaction can be collaborative, professional hierarchies and discipline-specific patterns of socialisation can result in unhealthy rivalry and conflicts which disrupt health system functioning. A better understanding of interprofessional dynamics is necessary to avoid such negative consequences. We, therefore, conducted a historical analysis of interprofessional interactions and role-boundary negotiations between health professions in Nigeria., Methods: We conducted a review of both published and grey literature to provide historical accounts and enable policy tracing of reforms related to interprofessional interactions. We used Nancarrow and Borthwick's typology for thematic analysis and used medical dominance and negotiated order theories to offer explanations of the conditions that facilitated or constrained interprofessional collaboration., Results: Despite an overall context of medical dominance, we found evidence of professional power changes (dynamics) and role-boundary shifts between health professions. These shifts occurred in different directions, but shifts between professions that are at different power gradients were more likely to be non-negotiable or conflictual. Conditions that facilitated consensual role-boundary shifts included the feasibility of simultaneous upward expansion of roles for all professions and the extent to which the delegating profession was in charge of role delegation. While the introduction of new medical diagnostic technology opened up occupational vacancies which facilitated consensual role-boundary change in some cases, it constrained professional collaboration in others., Conclusions: Health workforce governance can contribute to better functioning of health systems and voiding dysfunctional interprofessional relations if the human resource for health interventions are informed by contextual understanding (informed by comparative institutional and health systems research) of conditions that facilitate or constrain effective interprofessional collaboration., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

It is very exceptional that a new disease becomes a true pandemic. Since its emergence in Wuhan, China, in late 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, has spread to nearly all countries of the world in only a few months. However, in different countries, the COVID-19 epidemic takes variable shapes and forms in how it affects communities. Until now, the insights gained on COVID-19 have been largely dominated by the COVID-19 epidemics and the lockdowns in China, Europe and the USA. But this variety of global trajectories is little described, analysed or understood. In only a few months, an enormous amount of scientific evidence on SARS-CoV-2 and COVID-19 has been uncovered (knowns). But important knowledge gaps remain (unknowns). Learning from the variety of ways the COVID-19 epidemic is unfolding across the globe can potentially contribute to solving the COVID-19 puzzle. This paper tries to make sense of this variability-by exploring the important role that context plays in these different COVID-19 epidemics; by comparing COVID-19 epidemics with other respiratory diseases, including other coronaviruses that circulate continuously; and by highlighting the critical unknowns and uncertainties that remain. These unknowns and uncertainties require a deeper understanding of the variable trajectories of COVID-19. Unravelling them will be important for discerning potential future scenarios, such as the first wave in virgin territories still untouched by COVID-19 and for future waves elsewhere., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Health system planners in low- and middle-income countries (LMIC) of the Asia-Pacific region seeking to reorient primary health care (PHC) systems to achieve universal health coverage may be hindered by lack of knowledge of what works in their setting. With limited resources for research available, it is important to identify evidence-based strategies for reorganising PHC delivery, determine where relevant evidence gaps exist and prioritise these for future study. This paper describes an approach for doing this using the best available evidence combined with consultation to establish evidence priorities. We first reviewed PHC organisational interventions in Asia-Pacific LMICs and ascertained evidence gaps. The largest gaps related to interventions to promote access to essential medicines, patient management tools, effective health promotion strategies and service planning and accountability. Evidence from Pacific Island countries was particularly scant. We then engaged an expert panel of 22 PHC stakeholders from seven Asia-Pacific LMICs in a Delphi exercise to identify priority questions for future research. Research priorities were: (1) identifying effective PHC service delivery models for chronic diseases; (2) devising sustainable models of disease integration; (3) optimising task shifting; (4) understanding barriers to care continuity; (5) projecting future PHC needs; and (6) designing appropriate PHC service packages. Notably, stakeholder-determined priorities reflected large, context-dependent system issues, while evidence gaps centred on discrete interventions. Future research on the organisation of PHC services in Asia-Pacific LMICs should incorporate codesign principles to engage researchers and national PHC system stakeholders, and innovative methods that build on existing evidence and account for system complexity., Competing Interests: Competing interests: None declared.

Introduction: This paper synthesises evidence on the organisation of primary health care (PHC) service delivery in low-income and middle-income countries (LMICs) in the Asia Pacific and identifies evidence of effective approaches and pathways of impact in this region., Methods: We developed a conceptual framework describing key inputs and outcomes of PHC as the basis of a systematic review. We searched exclusively for intervention studies from LMICs of the Asia-Pacific region in an effort to identify 'what works' to improve the coverage, quality, efficiency, equity and responsiveness of PHC. We conducted a narrative synthesis to identify key characteristics of successful interventions., Results: From an initial list of 3001 articles, we selected 153 for full-text review and included 111. We found evidence on the impact of non-physician health workers (NPHWs) on coverage and quality of care, though better integration with other PHC services is needed. Community-based services are most effective when well integrated through functional referral systems and supportive supervision arrangements, and have a reliable supply of medicines. Many studies point to the importance of community engagement in improving service demand. Few studies adopted a 'systems' lens or adequately considered long-term costs or implementation challenges., Conclusion: Based on our findings, we suggest five areas where more practical knowledge and guidance is needed to support PHC systems strengthening: (1) NPHW workforce development; (2) integrating non-communicable disease prevention and control into the basic package of care; (3) building managerial capacity; (4) institutionalising community engagement; (5) modernising PHC information systems., Competing Interests: Competing interests: The authors declare that this research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. SA is the editor in chief of BMJ Global Health, but was not involved in the evaluation or peer-review process of this article.

Introduction: Interventions targeting the financing of primary health care (PHC) systems could accelerate progress towards universal health coverage; however, there is limited evidence to guide best-practice implementation of these interventions. This study aimed to generate a stakeholder-led research agenda in the area of PHC financing interventions in the Asia-Pacific region., Methods: We adopted a two-stage process: (1) a systematic review of financing interventions targeting PHC service delivery in the Asia-Pacific region was conducted to develop an evidence gap map and (2) an electronic-Delphi (e-Delphi) exercise with key national PHC stakeholders was undertaken to prioritise these evidence needs., Results: Thirty-one peer-reviewed articles (including 10 systematic reviews) and 10 grey literature reports were included in the review. There was limited consistency in results across studies but there was evidence that some interventions (removal of user fees, ownership models of providers and contracting arrangements) could impact PHC service access, efficiency and out-of-pocket cost outcomes. The e-Delphi exercise highlighted the importance of contextual factors and prioritised research in the areas of: (1) interventions to limit out-of-pocket costs; (2) financing models to enhance health system performance and maintain PHC budgets; (3) the design of incentives to promote optimal care without unintended consequences and (4) the comparative effectiveness of different PHC service delivery strategies using local data., Conclusion: The research questions which were deemed most important by stakeholders are not addressed in the literature. There is a need for more research on how financing interventions can be implemented at scale across health systems. Such research needs to be pragmatic and balance academic rigour with practical considerations., Competing Interests: Competing interests: SA is the editor in chief of BMJ Global Health but was not involved in the evaluation or peer-review process of this article. The other authors declare no competing interests for this work.

Introduction: A number of factors contribute to the performance and motivation of India's Accredited Social Health Activists (ASHAs). This study aims to identify the key motivational factors (and their relative importance) that may help retain ASHAs in service., Methods: A discrete choice experiment (DCE) survey presented ASHAs with eight unlabelled choice sets, each describing two hypothetical jobs that varied based on five attributes, specifically salary, workload, travel allowance, supervision and other job benefits. Multinomial logit and latent class (LC) models were used to estimate stated preferences for the attributes., Result: We invited 318 ASHAs from 53 primary health centres of Guntur, a district in south India. The DCE was completed by 299 ASHAs using Android tablets. ASHAs were found to exhibit a strong preference for jobs that incorporated training leading to promotion, a fixed salary and free family healthcare. ASHAs were willing to sacrifice 2530 Indian rupee (INR) from their monthly salary, for a job offering training leading to promotion opportunity and 879 INR for a free family health-check. However, there was significant heterogeneity in preferences across the respondents. The LC model identified three distinct groups (comprising 51%, 35% and 13% of our cohort, respectively). Group 1 and 2 preferences were dominated by the training and salary attributes with group 2 having higher preference for free family health-check while group 3 preferences were dominated by workload. Relative to group 3, ASHAs in groups 1 and 2 were more likely to have a higher level of education and less likely to be the main income earners for their families., Conclusion: ASHAs are motivated by both non-financial and financial factors and there is significant heterogeneity between workers. Policy decisions aimed at overcoming workforce attrition should target those areas that are most valued by ASHAs to maximise the value of investments into these workers., Trial Registration Number: CTRI/2018/03/012425., Competing Interests: Competing interests: None declared.

Efforts to strengthen health systems require the engagement of diverse, multidisciplinary stakeholder networks. Networks provide a forum for experimentation and knowledge creation, information exchange and the spread of good ideas and practice. They might be useful in addressing complex issues or 'wicked' problems, the solutions to which go beyond the control and scope of any one agency. Innovation platforms are proposed as a novel type of network because of their diverse stakeholder composition and focus on problem solving within complex systems. Thus, they have potential applicability to health systems strengthening initiatives, even though they have been predominantly applied in the international agricultural development sector. In this paper, we compare and contrast the concept of innovation platforms with other types of networks that can be used in efforts to strengthen primary healthcare systems, such as communities of practice, practice-based research networks and quality improvement collaboratives. We reflect on our ongoing research programme that applies innovation platform concepts to drive large-scale quality improvement in primary healthcare for Aboriginal and Torres Strait Islander Australians and outline our plans for evaluation. Lessons from our experience will find resonance with others working on similar initiatives in global health., Competing Interests: Competing interests: The authors declare that this research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. SA is the editor in chief of BMJ Global Health, but was not involved in the evaluation or peer-review process of this article.

Introduction: Community health workers (CHWs) are increasingly being tasked to prevent and manage cardiovascular disease (CVD) and its risk factors in underserved populations in low-income and middle-income countries (LMICs); however, little is known about the required training necessary for them to accomplish their role. This review aimed to evaluate the training of CHWs for the prevention and management of CVD and its risk factors in LMICs., Methods: A search strategy was developed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and five electronic databases (Medline, Global Health, ERIC, EMBASE and CINAHL) were searched to identify peer-reviewed studies published until December 2016 on the training of CHWs for prevention or control of CVD and its risk factors in LMICs. Study characteristics were extracted using a Microsoft Excel spreadsheet and quality assessed using Effective Public Health Practice Project's Quality Assessment Tool. The search, data extraction and quality assessment were performed independently by two researchers., Results: The search generated 928 articles of which 8 were included in the review. One study was a randomised controlled trial, while the remaining were before-after intervention studies. The training methods included classroom lectures, interactive lessons, e-learning and online support and group discussions or a mix of two or more. All the studies showed improved knowledge level post-training, and two studies demonstrated knowledge retention 6 months after the intervention., Conclusion: The results of the eight included studies suggest that CHWs can be trained effectively for CVD prevention and management. However, the effectiveness of CHW trainings would likely vary depending on context given the differences between studies (eg, CHW demographics, settings and training programmes) and the weak quality of six of the eight studies. Well-conducted mixed-methods studies are needed to provide reliable evidence about the effectiveness and cost-effectiveness of training programmes for CHWs., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Competing Interests: Competing interests: None declared.