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Background This is the sixth of our 11-paper supplement entitled “Community Health Workers at the Dawn of New Era”. Expectations of community health workers (CHWs) have expanded in recent years to encompass a wider array of services to numerous subpopulations, engage communities to collaborate with and to assist health systems in responding to complex and sometimes intensive threats. In this paper, we explore a set of key considerations for training of CHWs in response to their enhanced and changing roles and provide actionable recommendations based on current evidence and case examples for health systems leaders and other stakeholders to utilize. Methods We carried out a focused review of relevant literature. This review included particular attention to a 2014 book chapter on training of CHWs for large-scale programmes, a systematic review of reviews about CHWs, the 2018 WHO guideline for CHWs, and a 2020 compendium of 29 national CHW programmes. We summarized the findings of this latter work as they pertain to training. We incorporated the approach to training used by two exemplary national CHW programmes: for health extension workers in Ethiopia and shasthya shebikas in Bangladesh. Finally, we incorporated the extensive personal experiences of all the authors regarding issues in the training of CHWs. Results The paper explores three key themes: (1) professionalism, (2) quality and performance, and (3) scaling up. Professionalism: CHW tasks are expanding. As more CHWs become professionalized and highly skilled, there will still be a need for neighbourhood-level voluntary CHWs with a limited scope of work. Quality and performance: Training approaches covering relevant content and engaging CHWs with other related cadres are key to setting CHWs up to be well prepared. Strategies that have been recently integrated into training include technological tools and provision of additional knowledge; other strategies emphasize the ongoing value of long-standing approaches such as regular home visitation. Scale-up: Scaling up entails reaching more people and/or adding more complexity and quality to a programme serving a defined population. When CHW programmes expand, many aspects of health systems and the roles of other cadres of workers will need to adapt, due to task shifting and task sharing by CHWs. Conclusion Going forward, if CHW programmes are to reach their full potential, ongoing, up-to-date, professionalized training for CHWs that is integrated with training of other cadres and that is responsive to continued changes and emerging needs will be essential. Professionalized training will require ongoing monitoring and evaluation of the quality of training, continual updating of pre-service training, and ongoing in-service training—not only for the CHWs themselves but also for those with whom CHWs work, including communities, CHW supervisors, and other cadres of health professionals. Strong leadership, adequate funding, and attention to the needs of each cadre of CHWs can make this possible.

Introduction: There is limited guidance on strategies for delivering complex global health programs. We synthesized available evidence on implementation strategies and outcomes utilized in the global polio eradication initiative (GPEI) across low and middle-income country (LMIC) settings. Methods: We nested our scoping review into a literature review conducted as part of a parent study, STRIPE. This review systematically searched PubMed for articles between 1 January 1988 and 25 April 2018 using polio search terms. Strategies from included studies were organized according to the Expert Recommendations for Implementing Change (ERIC) framework, specified using Proctor’s framework, and linked to various outcomes (implementation, services delivery, impact).Results: 152 unique articles fulfilled our inclusion criteria (from 1,885 articles included in the parent study). Only 43 out of the 152 articles described a suitable quantitative study design for evaluating outcomes. We extracted 66 outcomes from the 43 unique studies. Study publication dates ranged from 1989-2018 and represented diverse country settings. The most common implementation strategies were developing mechanisms for feedback, monitoring, and evaluation (n=69); increasing awareness among the population (n=58); involving stakeholders, workers, and consumers in the implementation efforts (n=46); conducting workshops (n=33); using mass media (n=31); and building robust record systems to capture outcomes (n=31). Coverage (n=13) and morbidity (n=12) were the most frequently identified outcomes, followed by effectiveness (n=9) and fidelity (n=6). Coverage of polio vaccination was the most common implementation outcome, followed by acceptability and fidelity. Feasibility and sustainability were rarely evaluated.Conclusions: This review provides a catalogue of implementation strategies and outcomes relevant for advancing global health services delivery in LMICs drawing from the GPEI. Implementation strategies reviewed were poorly described and not adequately linked to outcomes. It calls for additional implementation research to unravel the mechanisms of implementation strategies and their effectiveness, and adaptation of the ERIC framework in LMICs. Systematic Review Registration: N/A

Universal health coverage (UHC) depends on a strong primary health-care system. To be successful, primary health care must be expanded at community and household levels as much of the world's population still lacks access to health facilities for basic services. Abundant evidence shows that community-based interventions are effective for improving health-care utilization and outcomes when integrated with facility-based services. Community involvement is the cornerstone of local, equitable and integrated primary health care. Policies and actions to improve primary health care must regard community members as more than passive recipients of health care. Instead, they should be leaders with a substantive role in planning, decision-making, implementation and evaluation. Advancing the science of primary health care requires improved conceptual and analytical frameworks and research questions. Metrics used for evaluating primary health care and UHC largely focus on clinical health outcomes and the inputs and activities for achieving them. Little attention is paid to indicators of equitable coverage or measures of overall well-being, ownership, control or priority-setting, or to the extent to which communities have agency. In the future, communities must become more involved in evaluating the success of efforts to expand primary health care. Much of primary health care has taken place, and will continue to take place, outside health facilities. Involving community members in decisions about health priorities and in community-based service delivery is key to improving systems that promote access to care. Neither UHC nor the Health for All movement will be achieved without the substantial contribution of communities.La couverture maladie universelle (CMU) repose sur un solide système de soins de santé primaires. Pour rendre les soins de santé primaires efficaces, il faut les étendre aux communautés et aux ménages car la majorité de la population mondiale n'a toujours pas accès aux structures médicales offrant des services de base. Nombreux sont les éléments qui prouvent que les interventions communautaires contribuent à améliorer l'utilisation des soins de santé et les résultats cliniques lorsqu'elles font partie intégrante des services proposés au sein des établissements. L'implication des communautés constitue la clé de voûte d'un système de soins de santé primaires local, équitable et intégré. Les politiques et actions visant à le renforcer doivent tenir compte des membres des communautés, et ne pas se limiter à les considérer comme des bénéficiaires passifs de soins de santé. Au contraire, leurs dirigeants devraient jouer un rôle prépondérant dans la planification, la prise de décisions, la mise en œuvre et l'évaluation. Faire progresser la science des soins de santé primaires requiert une optimisation des cadres analytiques et conceptuels, ainsi que des questions de recherche. Les paramètres employés pour évaluer les soins de santé primaires et la CMU se concentrent souvent sur les résultats cliniques, sur les activités et moyens utilisés pour les atteindre. Peu d'attention est accordée aux indicateurs d'une couverture équitable, ou aux mesures de bien-être général, de possession, de contrôle ou de définition des priorités, ou encore à l'étendue du pouvoir d'action des communautés. À l'avenir, les communautés doivent s'engager davantage dans l'évaluation de la réussite des efforts déployés pour développer les soins de santé primaires. La plupart de ces soins ont toujours été et continueront à être prodigués en dehors des structures médicales. Impliquer les membres des communautés dans les décisions destinées à définir les priorités sanitaires et la fourniture de services communautaires est essentiel pour améliorer des systèmes qui permettront de promouvoir l'accès aux soins. Ni la CMU, ni le mouvement «Santé pour tous» ne parviendront à leurs fins sans la contribution majeure des communautés.La cobertura sanitaria universal (CSU) depende de un sistema de atención primaria de salud sólido. Sin embargo, la atención primaria de salud se debe ampliar a nivel de la comunidad y de los hogares para que logre resultados efectivos, ya que gran parte de la población mundial sigue sin tener acceso a los centros de salud para recibir los servicios básicos. Existen muchas pruebas que demuestran que las intervenciones basadas en la comunidad son efectivas para mejorar el uso y los resultados de la atención de la salud cuando se integran con los servicios que se prestan en los centros de salud. La participación de la comunidad es el elemento fundamental de la atención primaria de salud local, equitativa e integrada. Las políticas y las medidas para mejorar la atención primaria de salud deben tener en cuenta que los miembros de la comunidad son más que receptores pasivos de la atención de salud. Por el contrario, deben ser líderes con una función importante en la planificación, la toma de decisiones, la implementación y la evaluación. El progreso de la ciencia en la atención primaria de salud requiere mejorar los marcos conceptuales y analíticos y los temas de investigación. Los parámetros que se usan para evaluar la atención primaria de salud y la CSU se centran en gran medida en los resultados clínicos de la salud y en los recursos y las actividades que permiten alcanzarlos. Se presta poca atención a los indicadores de cobertura equitativa o a las medidas de bienestar general, propiedad, control o establecimiento de prioridades, o a la medida en que las comunidades participan activamente. Por consiguiente, las comunidades deben participar más en la evaluación del éxito de los esfuerzos por ampliar la atención primaria de salud en el futuro. Gran parte de la atención primaria de salud siempre ha tenido y seguirá teniendo lugar fuera de los centros de salud. La participación de los miembros de la comunidad en las decisiones sobre las prioridades sanitarias y en la prestación de servicios comunitarios es fundamental para mejorar los sistemas que promueven el acceso a la atención, ya que ni la CSU ni el movimiento Salud para Todos se lograrán si las comunidades no contribuyen de manera sustancial.تعتمد التغطية الصحية الشاملة (UHC) على نظام قوي للرعاية الصحية الأولية. لتحقيق النجاح، يجب توسيع نطاق الرعاية الصحية الأولية في المجتمع وعلى المستويات الأسرية نظرًا لأن الكثير من سكان العالم لا يزالوا يفتقرون إلى إمكانية الاستفادة من المرافق الصحية للحصول على الخدمات الأساسية. تشير وفرة من الأدلة أن التدخلات المجتمعية تتميز بالفعالة في تحسين الاستفادة من الرعاية الصحية، ونتائجها عندما تتكامل مع الخدمات المعتمدة على المرافق. تعد المشاركة المجتمعية بمثابة حجر الزاوية للرعاية الصحية الأولية المحلية العادلة المتكاملة. إن السياسات والإجراءات المتبعة لتحسين الرعاية الصحية الأولية يجب أن تضع في اعتبارها أفراد المجتمع على أنهم أكثر من مجرد متلقين سلبيين للرعاية الصحية. وبدلاً من ذلك، يجب أن يكونوا قادة لهم دور جوهري في التخطيط، واتخاذ القرار، والتنفيذ، والتقييم. إن الارتقاء بعلم الرعاية الصحية الأولية يتطلب إطارات مفاهيمية وتحليلية وأسئلة بحثية محسنة. تركز المقاييس المستخدمة لتقييم الرعاية الصحية الأولية والتغطية الصحية الشاملة (UHC) بشكل كبير على النتائج الصحية السريرية، والمدخلات والأنشطة المتاحة لتحقيقها. لا تستحوذ مؤشرات التغطية العادلة، أو مقاييس الرفاهية العامة، أو الملكية، أو السيطرة، أو تحديد الأولويات، أو المدى الذي تتمتع به المجتمعات المحلية بالتمثيل، إلا بالقليل من الاهتمام. في المستقبل، يجب أن تصبح المجتمعات أكثر مشاركة في تقييم نجاح الجهود المبذولة لتوسيع نطاق الرعاية الصحية الأولية. كان ولا يزال قدر كبير من الرعاية الصحية الأولية يتم دائمًا خارج المرافق الصحية. إن إشراك أفراد المجتمع في القرارات المتعلقة بالأولويات الصحية، وفي تقديم الخدمات المجتمعية، أمر أساسي لتحسين الأنظمة التي تعزز الحصول على الرعاية. لن تتحقق التغطية الصحية الشاملة (UHC)، ولا حركة "الصحة للجميع" دون مساهمة كبيرة من المجتمعات.全民健康覆盖 (UHC) 取决于强大的初级卫生保健体系。世界上还有很多人无法享受卫生机构提供的基本服务,因此必须在社区和家庭大力推广初级卫生保健,才能实现全民健康覆盖。大量证据表明,社区干预结合机构服务可有效提高卫生保健服务利用率,并改善其成效。社区参与是实现地方公平和一体化初级卫生保健的基石。就初级卫生保健的改善政策和措施而言,不可将社区成员仅视为被动接受卫生保健服务的人。相反,他们应该是在规划、决策、实施和评估中发挥实质性作用的带头人。要推进初级卫生保健科学,就需要改进概念、分析框架以及研究问题。初级卫生保健和 UHC 的评估指标,主要侧重于临床卫生成效以及达成该成效的投入和举措。而很少关注公平覆盖的指标,或总体福祉、所有权、控制权或明确优先事项的措施,或社区具有的代理权程度。今后,社区必须更积极参与评估推广初级卫生保健的成功程度。许多初级卫生保健一直并将继续在卫生机构以外进行。让社区成员参与卫生工作重点决策以及社区服务,是改善体系的关键,可以让更多人获得保健机会。如果没有社区的大力协助,UHC 和全民健康都将无法实现。.Всеобщий охват услугами здравоохранения (ВОУЗ) зависит от наличия сильной системы первичной медико-санитарной помощи. Для достижения успеха первичную медико-санитарную помощь следует расширить на уровне сообществ и домашних хозяйств, поскольку большая часть населения мира по-прежнему не имеет доступа к учреждениям здравоохранения для получения основных услуг. Многочисленные доказательства демонстрируют, что меры, предпринимаемые на уровне сообществ, эффективны для улучшения использования услуг здравоохранения и результатов, если они объединены с услугами на базе учреждений. Участие сообщества является краеугольным камнем местной, равнодоступной и объединенной первичной медико-санитарной помощи. Политика и действия по улучшению первичной медико-санитарной помощи должны рассматривать членов сообщества как нечто большее, чем просто пассивных получателей медицинской помощи. Наоборот, сообщества должны быть лидерами, играющими существенную роль в планировании, принятии решений, реализации и оценке. Развитие научных знаний о первичной медико-санитарной помощи требует улучшенных концептуальных и аналитических механизмов и исследовательских вопросов. Показатели, используемые для оценки первичной медико-санитарной помощи и всеобщего охвата услугами здравоохранения, в основном сосредоточены на клинических результатах в отношении здоровья, а также на затрачиваемых на это ресурсах и мероприятиях по их достижению. Мало внимания уделяется индикаторам справедливого охвата, измерению общего благосостояния, сопричастности, контроля или определения приоритетов или тому, насколько у сообщества имеется возможность действовать. В будущем сообщества необходимо более активно привлекать к оценке успеха усилий по расширению первичной медико-санитарной помощи. Большая часть первичной медико-санитарной помощи всегда оказывалась и будет оказываться вне учреждений здравоохранения. Вовлечение членов сообществ в решения о приоритетах сферы здравоохранения и о предоставлении услуг на уровне сообщества является ключевым фактором в усовершенствовании систем, способствующих улучшению доступа к медицинской помощи. Ни всеобщего охвата услугами здравоохранения, ни движения «Здоровье для всех» невозможно достичь без существенного вклада сообществ.

Background. The Sustaining Technical and Analytical Resources (STAR) project seeks to invest in and expand the capacity of diverse senior global public health professionals. STAR builds on traditional work-based fellowships by partnering with universities in order to curate (or develop) and deliver high-quality, tailored learning across a set of required “core competency domains” as well as elective skills- or content-based competency domains. Pedagogy. In a rapidly changing global health context, ongoing learning is essential but often gets sidelined by other pressures; STAR’s approach aims to respond to these challenges by developing a learning curriculum tailored to the needs of our participants and their roles in global health. STAR’s pedagogy utilizes individualized learning plans, a deliberate practice approach, and a hybrid mentorship model to support project participants to achieve their learning objectives as well as broader project goals. Next Steps. The STAR project is in its first year of implementation. Furthermore, our future work will focus on developing a monitoring and evaluation plan that seeks to track the progress of our participants, guide project improvements, measure the impact of learning activities, and inform the pedagogy of future global health training initiatives.

IntroductionLearning health systems (LHS) is a multifaceted subject. This paper reviewed current concepts as well as real-world experiences of LHS, drawing on published and unpublished knowledge in order to identify and describe important principles and practices that characterise LHS in low/middle-income country (LMIC) settings.MethodsWe adopted an exploratory approach to the literature review, recognising there are limited studies that focus specifically on system-wide learning in LMICs, but a vast set of connected bodies of literature. 116 studies were included, drawn from an electronic literature search of published and grey literature. In addition, 17 interviews were conducted with health policy and research experts to gain experiential knowledge.ResultsThe findings were structured by eight domains on learning enablers. All of these interact with one another and influence actors from community to international levels.We found that learning comes from the connection between information, deliberation, and action. Moreover, these processes occur at different levels. It is therefore important to consider experiential knowledge from multiple levels and experiences. Creating spaces and providing resources for communities, staff and managers to deliberate on their challenges and find solutions has political implications, however, and is challenging, particularly when resources are constrained, funding and accountability are fragmented and the focus is short-term and narrow. Nevertheless, we can learn from countries that have managed to develop institutional mechanisms and human capacities which help health systems respond to changing environments with ‘best fit’ solutions.ConclusionHealth systems are knowledge producers, but learning is not automatic. It needs to be valued and facilitated. Everyday governance of health systems can create spaces for reflective practice and learning within routine processes at different levels. This article highlights important enablers, but there remains much work to be done on developing this field of knowledge.

Background Developing public health educational programs that provide workers prepared to adequately respond to health system challenges is an historical dilemma. In India, the focus on public health education has been mounting in recent years. The COVID-19 pandemic is a harbinger of the increasing complexities surrounding public health challenges and the overdue need to progress public health education around the world. This paper aims to explore strengths and challenges of public health educational institutions in India, and elucidate unique opportunities to emerge as a global leader in reform. Methods To capture the landscape of public health training in India, we initiated a web-based desk review of available offerings and categorized by key descriptors and program qualities. We then undertook a series of in-depth interviews with representatives from a purposively sample of institutions and performed a qualitative SWOT analysis. Results We found that public health education exists in many formats in India. Although Master of Public Health (MPH) and similar programs are still the most common type of public health training outside of community medicine programs, other postgraduate pathways exist including diplomas, PhDs, certificates and executive trainings. The strengths of public health education institutions include research capacities, financial accessibility, and innovation, yet there is a need to improve collaborations and harmonize training with well-defined career pathways. Growing attention to the sector, improved technologies and community engagement all hold exciting potential for public health education, while externally held misconceptions can threaten institutional efficacy and potential. Conclusions The timely need for and attention to public health education in India present a critical juncture for meaningful reform. India may also be well-situated to contextualize and scale the types of trainings needed to address complex challenges and serve as a model for other countries and the world.

Objectives: This paper aims to depict unique perspectives and to compare and contrast three leadership programs for global health in order to enable other training institutions to design impactful curricula. Methods: We purposively selected three global health training programs. We used a six-step curriculum development framework to systematically compare the curriculum process across programs and to identify best practices and factors contributing to the impact of each of these programs. Findings: All three fellowship programs undertook an intentional and in-depth approach to curriculum development. Each identified competencies related to leadership and technical skills. Each defined goals, though the goals differed to align with the desired impact of the program, ranging from improving the impact of HIV programming, supporting stronger global health program implementation, and supporting the next generation of global health leaders. All programs implemented the curriculum through an onboarding phase, a delivery of core content in different formats, and a wrap-up or endline phase. During implementation, each program also utilized networking and mentoring to enhance connections and to support application of learning in work roles. Programs faced overlapping challenges and opportunities including funding, strengthening partnerships, and finding ways to engage and support alumni. Conclusions: Local ownership of programs is critical, including tailoring curricula to the needs of specific contexts. Strong partnerships and resources are needed to ensure program sustainability and impact. Key Takeaways Global health competencies and curricula should be linked to local health system needs and contexts where learners are working. Emphasizing both individualistic and collectivist approaches to learning is important in engaging and supporting diverse global health learners. Emphasizing mentorship and opportunities to apply learning in contexts where learners are working is important in order to provide support to learners as they work to integrate what they are learning into their professional roles and activities. Partnerships and resources—including donor support—are essential to implement and sustain robust leadership curricula and to provide opportunities for experiential and didactic learning.

Background: Public health training has been expanding in India in recent years. The COVID-19 pandemic has brought additional attention to the importance of public health programs and the need for a strong workforce. This paper aims to assess the current capacity for public health education and training in India and provide recommendations for improved approaches to meet current and future public health needs. Methods: We conducted a desk review of public health training programs via extensive internet searches, literature reviews and expert faculty consultations. Among those programs, we purposively selected faculty members to participate in in-depth interviews. We developed summary statistics based on the desk review. For qualitative analysis, we utilized a combination of deductive and inductive coding to identify key themes and systematically reviewed strengths and weaknesses for each theme. Results: The desk review captured 59 institutions offering public health training across India. The majority of training programs were graduate level degrees including master of public health (MPH) and master of science (MS) degrees. Key themes included collaborations, mentorship, curriculum standardization, tuition and funding, and student demand for public health education and careers. Collaborations and mentorship were highly valued but varied in quality across institutions. Curricula lacked standardization but also contained substantial flexibility and innovation as a result. Public sector programs were affordable and student stipend varied across institutions. Further development of the demand-side with greater opportunities for career for careers in public health is needed. Conclusion: Public health education and training in India has a strong foothold. There are numerous opportunities for continued expansion and strengthening of this field, to support a robust multi-disciplinary public health workforce that will contribute towards achieving the sustainable development goals.

Background: As the field of health policy and systems research (HPSR) continues to grow, there is a recognition of the need for training in HPSR. This aspiration has translated into a multitude of teaching programmes of variable scope and quality, reflecting a lack of consensus on the skills and practices required for rigorous HPSR. The purpose of this paper is to identify an agreed set of core competencies for HPSR researchers, building on the previous work by the Health Systems Global (HSG) Thematic Working Group on Teaching & Learning. Methods: Our methods involved an iterative approach of four phases including a literature review, key informant interviews and group discussions with HPSR educators, and webinars with pre-post surveys capturing views among the global HPSR community. The phased discussions and consensus-building contributed to the evolution of the HPSR competency domains and competencies framework. Results: Emerging domains included understanding health systems complexity, assessing policies and programs, appraising data and evidence, ethical reasoning and practice, leading and mentoring, building partnerships, and translating and utilizing knowledge and HPSR evidence. The development of competencies and their application were often seen as a continuous process spanning evidence generation, partnering, communicating and helping to identify new critical health systems questions. Conclusion: The HPSR competency set can be seen as a useful reference point in the teaching and practice of high-quality HPSR and can be adapted based on national priorities, the particularities of local contexts, and the needs of stakeholders (HPSR researchers and educators), as well as practitioners and policy-makers. Further research is needed in using the core competency set to design national training programmes, develop locally relevant benchmarks and assessment methods, and evaluate their use in different settings.

The rural United States, including West Virginia, has decades of experience engaging communities and utilizing community health workers (CHWs). This study aims to inform policy and planning by comparing how 2 county-level CHW programs engage with communities. The analysis is based on in-depth interviews with 19 community representatives and 20 health workers and archival documents and published literature reviews. Results highlight the local contextual determinants for community engagement with CHW programs. Making CHW policies inclusive and adaptable to local realities will enable more community benefits. Making the value of CHW programs for communities explicit should guide resource allocation and policies.

BackgroundAs the field of global health expands, the recognition of structured training for field-based public health professionals has grown. Substantial effort has gone towards defining competency domains for public health professionals working globally. However, there is limited literature on how to implement competency-based training into learning curricula and evaluation strategies.ObjectivesThis scoping review seeks to collate the current status, degree of consensus, and best practices, as well as gaps and areas of divergence, related to the implementation of competencies in global health curricula. Specifically, we sought to examine (i) the target audience, (ii) the levels or milestones, and (iii) the pedagogy and assessment approaches.Sources of evidenceA review of the published and grey literature was completed to identify published and grey literature sources that presented information on how to implement or support global health and public health competency-based education programs. In particular, we sought to capture any attempts to assign levels or milestones, any evaluation strategies, and the different pedagogical approaches.ResultsOut of 68 documents reviewed, 21 documents were included which contained data related to the implementation of competency-based training programs; of these, 18 were peer-reviewed and three were from the grey literature. Most of the sources focused on post-graduate public health students, professional trainees pursuing continuing education training, and clinical and allied health professionals working in global health. Two approaches were identified to defining skill level or milestones, namely: (i) defining levels of increasing ability or (ii) changing roles across career stages. Pedagogical approaches featured field experience, direct engagement, group work, and self-reflection. Assessment approaches included self-assessment surveys, evaluations by peers and supervisors, and mixed methods assessments.ConclusionsThe implementation of global health competencies needs to respond to the needs of specific agencies or particular groups of learners. A milestones approach may aide these efforts while also support monitoring and evaluation. Further development is needed to understand how to assess competencies in a consistent and relevant manner.

Background Evidence-based decision-making is crucial to leadership in the health sector to identify country-level priorities and generate solutions supported by rigorous research. Barriers and enablers have been explored, but limited evidence about what works to strengthening capacity at individual and institutional levels within countries has been reported, and inconsistent use of evidence to inform policy-making is a persistent challenge and concern. Methods We conducted a framework analysis comparing experiences of nine purposively selected countries (Chile, Ethiopia, Ghana, Kyrgyzstan, Lebanon, Mozambique, Rwanda, South Africa and Sri Lanka). We utilised qualitative case studies developed by in-country teams to explore enablers and barriers described across components of a predefined theory of change and then identified six cross-cutting themes and recommendations for relevant stakeholders associated with each theme. Results The cross-cutting themes included (1) leadership and political will, (2) incentives and resources, (3) infrastructure and access to health data, (4) designated structures and processes, (5) interaction and relationships, and (6) capacity strengthening and engagement. While each case country’s context and experience was different, common enablers and barriers surfaced across each of these themes, with Ministries of Health and other government agencies having strong roles to play, but also recognising the need for other stakeholders, including researchers, donors and civil society, to serve as essential collaborators in order to strengthen evidence uptake. Substantial and sustained investment in research capacities, able leaders and stronger engagement of civil servants are needed to further this progress and strengthen processes of health decision-making. Conclusions All countries represented in this study have made commendable progress in increasing evidence uptake and strengthening supportive systems. Establishing and strengthening necessary structures and the relationships that underpin them takes time as well as resources. Going forward, the findings from this study can help guide and support advocacy to increase domestic funding for health research, especially health policy and systems research, and ensure that civil servants as well as researchers have the capacity and support to collaborate and continue to bolster evidence uptake.

Community-based approaches are a critical foundation for many health outcomes, including reproductive, maternal, newborn and child health (RMNCH). Evidence is a vital part of strengthening that foundation, but largely focuses on the technical content of what must be done, rather than on how disparate community actors continuously interpret, implement and adapt interventions in dynamic and varied community health systems. We argue that efforts to strengthen evidence for community programmes must guard against the hubris of relying on a single approach or hierarchy of evidence for the range of research questions that arise when sustaining community programmes at scale. Moving forward we need a broader evidence agenda that better addresses the implementation realities influencing the scale and sustainability of community programmes and the partnerships underpinning them if future gains in community RMNCH are to be realised. This will require humility in understanding communities as social systems, the complexity of the interventions they engage with and the heterogeneity of evidence needs that address the implementation challenges faced. It also entails building common ground across epistemological word views to strengthen the robustness of implementation research by improving the use of conceptual frameworks, addressing uncertainty and fostering collaboration. Given the complexity of scaling up and sustaining community RMNCH, ensuring that evidence translates into action will require the ongoing brokering of relationships to support the human creativity, scepticism and scaffolding that together build layers of evidence, critical thinking and collaborative learning to effect change.

Background This paper assesses the effectiveness of community–based primary health care (CBPHC) in improving child health beyond the neonatal period. Although there has been an accelerated decline in global under–5 mortality since 2000, mortality rates remain high in much of sub–Saharan Africa and in some south Asian countries where under–5 mortality is also decreasing more slowly. Essential interventions for child health at the community level have been identified. Our review aims to contribute further to this knowledge by examining how strong the evidence is and exploring in greater detail what specific interventions and implementation strategies appear to be effective. Methods We reviewed relevant documents from 1950 onwards using a detailed protocol. Peer reviewed documents, reports and books assessing the impact of one or more CBPHC interventions on child health (defined as changes in population coverage of one or more key child survival interventions, nutritional status, serious morbidity or mortality) among children in a geographically defined population was examined for inclusion. Two separate reviews took place of each document followed by an independent consolidated summative review. Data from the latter review were transferred to electronic database for analysis. Results The findings provide strong evidence that the major causes of child mortality in resource–constrained settings can be addressed at the community level largely by engaging communities and supporting community–level workers. For all major categories of interventions (nutritional interventions; control of pneumonia, diarrheal disease and malaria; HIV prevention and treatment; immunizations; integrated management of childhood diseases; and comprehensive primary health care) we have presented randomized controlled trials that have consistently produced statistically significant and operationally important effects. Conclusions This review shows that there is strong evidence of effectiveness for CBPHC implementation of an extensive range of interventions to improve child health and that four major strategies for delivering these interventions are effective.

Background As the number of deaths among children younger than 5 years of age continues to decline globally through programs to address the health of older infants, neonatal mortality is becoming an increasingly large proportion of under-5 deaths. Lack of access to safe delivery care, emergency obstetric care and postnatal care continue to be challenges for reducing neonatal mortality. This article reviews the available evidence regarding the effectiveness of community-based primary health care (CBPHC) and common components of programs aiming to improve health during the first 28 days of life. Methods A database comprising evidence of the effectiveness of projects, programs and field research studies (referred to collectively as projects) in improving maternal, neonatal and child health through CBPHC has been assembled and described elsewhere in this series. From this larger database (N = 548), a subset was created from assessments specifically relating to newborn health (N = 93). Assessments were excluded if the primary project beneficiaries were more than 28 days of age, or if the assessment did not identify one of the following outcomes related to neonatal health: changes in knowledge about newborn illness, care seeking for newborn illness, utilization of postnatal care, nutritional status of neonates, neonatal morbidity, or neonatal mortality. Descriptive analyses were conducted based on study type and outcome variables. An equity assessment was also conducted on the articles included in the neonatal subset. Results There is strong evidence that CBPHC can be effective in improving neonatal health, and we present information about the common characteristics shared by effective programs. For projects that reported on health outcomes, twice as many reported an improvement in neonatal health as did those that reported no effect; only one study demonstrated a negative effect. Of those with the strongest experimental study design, almost three-quarters reported beneficial neonatal health outcomes. Many of the neonatal projects assessed in our database utilized community health workers (CHWs), home visits, and participatory women's groups. Several of the interventions used in these projects focused on health education (recognition of danger signs), and promotion of and support for exclusive breastfeeding (sometimes, but not always, including early breastfeeding). Almost all of the assessments that included a measurable equity component showed that CBPHC produced neonatal health benefits that favored the poorest segment of the project population. However, the studies were quite biased in geographic scope, with more than half conducted in South Asia, and many were pilot studies, rather than projects at scale. Conclusions CBPHC can be effectively employed to improve neonatal health in high-mortality, resource-constrained settings. CBPHC is especially important for education and support for pregnant and postpartum mothers and for establishing community-facility linkages to facilitate referrals for obstetrical emergencies; however, the latter will only produce better health outcomes if facilities offer timely, high-quality care. Further research on this topic is needed in Africa and Latin America, as well as in urban and peri-urban areas. Additionally, more assessments are needed of integrated packages of neonatal interventions and of programs at scale.

Background We summarize the findings of assessments of projects, programs, and research studies (collectively referred to as projects) included in a larger review of the effectiveness of community–based primary health care (CBPHC) in improving maternal, neonatal and child health (MNCH). Findings on neonatal and child health are reported elsewhere in this series. Methods We searched PUBMED and other databases through December 2015, and included assessments that underwent data extraction. Data were analyzed to identify themes in interventions implemented, health outcomes, and strategies used in implementation. Results 152 assessments met inclusion criteria. The majority of assessments were set in rural communities. 72% of assessments included 1–10 specific interventions aimed at improving maternal health. A total of 1298 discrete interventions were assessed. Outcome measures were grouped into five main categories: maternal mortality (19% of assessments); maternal morbidity (21%); antenatal care attendance (50%); attended delivery (66%) and facility delivery (69%), with many assessments reporting results on multiple indicators. 15 assessments reported maternal mortality as a primary outcome, and of the seven that performed statistical testing, six reported significant decreases. Seven assessments measured changes in maternal morbidity: postpartum hemorrhage, malaria or eclampsia. Of those, six reported significant decreases and one did not find a significant effect. Assessments of community–based interventions on antenatal care attendance, attended delivery and facility–based deliveries all showed a positive impact. The community–based strategies used to achieve these results often involved community collaboration, home visits, formation of participatory women’s groups, and provision of services by outreach teams from peripheral health facilities. Conclusions This comprehensive and systematic review provides evidence of the effectiveness of CBPHC in improving key indicators of maternal morbidity and mortality. Most projects combined community– and facility–based approaches, emphasizing potential added benefits from such holistic approaches. Community–based interventions will be an important component of a comprehensive approach to accelerate improvements in maternal health and to end preventable maternal deaths by 2030.

Background As part of our review of the evidence of the effectiveness of community-based primary health care (CBPHC) in improving maternal, neonatal and child health (MNCH), we summarize here the common delivery strategies of projects, programs and field research studies (collectively referred to as projects) that have demonstrated effectiveness in improving child mortality. Other articles in this series address specifically the effects of CBPHC on improving MNCH, while this paper explores the specific strategies used. Methods We screened 12 166 published reports in PubMed of community-based approaches to improving maternal, neonatal and child health in high-mortality, resource-constrained settings from 1950-2015. A total of 700 assessments, including 148 reports from other publicly available sources (mostly unpublished evaluation reports and books) met the criteria for inclusion and were reviewed using a data extraction form. Here we identify and categorize key strategies used in project implementation. Results Six categories of strategies for program implementation were identified, all of which required working in partnership with communities and health systems: (a) program design and evaluation, (b) community collaboration, (c) education for community-level staff, volunteers, beneficiaries and community members, (d) health systems strengthening, (e) use of community-level workers, and (f) intervention delivery. Four specific strategies for intervention delivery were identified: (a) recognition, referral, and (when possible) treatment of serious childhood illness by mothers and/or trained community agents, (b) routine systematic visitation of all homes, (c) facilitator-led participatory women's groups, and (d) health service provision at outreach sites by mobile health teams. Conclusions The strategies identified here provide useful starting points for program design in strengthening the effectiveness of CBPHC for improving MNCH.

Background The degree to which investments in health programs improve the health of the most disadvantaged segments of the population-where utilization of health services and health status is often the worst-is a growing concern throughout the world. Therefore, questions about the degree to which community-based primary health care (CBPHC) can or actually does improve utilization of health services and the health status of the most disadvantaged children in a population is an important one. Methods Using a database containing information about the assessment of 548 interventions, projects or programs (referred to collectively as projects) that used CBPHC to improve child health, we extracted evidence related to equity from a sub-set of 42 projects, identified through a multi-step process, that included an equity analysis. We organized our findings conceptually around a logical framework matrix. Results Our analysis indicates that these CBPHC projects, all of which implemented child health interventions, achieved equitable effects. The vast majority (87%) of the 82 equity measurements carried out and reported for these 42 projects demonstrated "pro-equitable" or "equitable" effects, meaning that the project's equity indicator(s) improved to the same degree or more in the disadvantaged segments of the project population as in the more advantaged segments. Most (78%) of the all the measured equity effects were "pro-equitable," meaning that the equity criterion improved more in the most disadvantaged segment of the project population than in the other segments of the population. Conclusions Based on the observation that CBPHC projects commonly provide services that are readily accessible to the entire project population and that even often reach down to all households, such projects are inherently likely to be more equitable than projects that strengthen services only at facilities, where utilization diminishes greatly with one's distance away. The decentralization of services and attention to and tracking of metrics across all phases of project implementation with attention to the underserved, as can be done in CBPHC projects, are important for reducing inequities in countries with a high burden of child mortality. Strengthening CBPHC is a necessary strategy for reducing inequities in child health and for achieving universal coverage of essential services for children.

To investigate the characteristics of health policy and systems research training globally and to identify recommendations for improvement and expansion.We identified institutions offering health policy and systems research training worldwide. In 2014, we recruited participants from identified institutions for an online survey on the characteristics of the institutions and the courses given. Survey findings were explored during in-depth interviews with selected key informants.The study identified several important gaps in health policy and systems research training. There were few courses in central and eastern Europe, the Middle East, North Africa or Latin America. Most (116/152) courses were instructed in English. Institutional support for courses was often lacking and many institutions lacked the critical mass of trained individuals needed to support doctoral and postdoctoral students. There was little consistency between institutions in definitions of the competencies required for health policy and systems research. Collaboration across disciplines to provide the range of methodological perspectives the subject requires was insufficient. Moreover, the lack of alternatives to on-site teaching may preclude certain student audiences such as policy-makers.Training in health policy and systems research is important to improve local capacity to conduct quality research in this field. We provide six recommendations to improve the content, accessibility and reach of training. First, create a repository of information on courses. Second, establish networks to support training. Third, define competencies in health policy and systems research. Fourth, encourage multidisciplinary collaboration. Fifth, expand the geographical and language coverage of courses. Finally, consider alternative teaching formats.Examiner les caractéristiques des formations à la recherche sur les politiques et les systèmes de santé dans le monde entier et proposer des recommandations en vue de les améliorer et de les étendre.Nous avons identifié des institutions qui proposent des formations à la recherche sur les politiques et les systèmes de santé dans le monde entier. En 2014, nous avons recruté des participants au sein des institutions identifiées pour mener une enquête en ligne sur les caractéristiques des institutions et sur les cours dispensés. Les résultats de cette enquête ont été étudiés lors d'entretiens approfondis avec des informateurs clés sélectionnés.L'étude a révélé plusieurs lacunes importantes dans les formations à la recherche sur les politiques et les systèmes de santé. Peu de cours sont proposés en Afrique du Nord, en Amérique latine, en Europe centrale et orientale et au Moyen-Orient. La plupart des cours (116/152) sont dispensés en anglais. Les soutiens institutionnels pour les cours sont rares, et de nombreuses institutions ne disposent pas de la masse critique d'individus suffisamment formés pour accompagner les étudiants pendant et après leur doctorat. La définition des compétences requises pour la recherche sur les politiques et les systèmes de santé manque d'homogénéité d'une institution à une autre. Les collaborations entre disciplines, qui permettent d'offrir toutes les perspectives méthodologiques nécessaires pour traiter ce sujet, restent insuffisantes. Par ailleurs, le manque de solutions alternatives aux cours dispensés sur place peut exclure certains publics étudiants, comme les responsables de l'élaboration des politiques.La formation à la recherche sur les politiques et les systèmes de santé est cruciale pour améliorer les capacités locales à réaliser des recherches de qualité en la matière. Nous proposons six recommandations pour améliorer le contenu, l'accessibilité et la portée de ces formations. Premièrement, créer une base de données de référence contenant toutes les informations sur les formations. Deuxièmement, créer des réseaux pour appuyer la formation. Troisièmement, définir les compétences requises pour la recherche sur les politiques et les systèmes de santé. Quatrièmement, encourager les collaborations multidisciplinaires. Cinquièmement, étendre la couverture géographique et linguistique des formations. Enfin, envisager des formats d'enseignement alternatifs.Investigar las características de la formación para la investigación en políticas y sistemas de salud a nivel global e identificar las recomendaciones para lograr mejoras y ampliaciones.Se identificaron instituciones que ofrecían formación para la investigación en políticas y sistemas de salud en todo el mundo. En 2014, se inscribieron participantes de instituciones identificadas para una encuesta en línea sobre las características de las instituciones y los cursos impartidos. Se exploraron los resultados de la encuesta durante entrevistas exhaustivas con informadores clave seleccionados.El estudio identificó numerosas deficiencias importantes con respecto a la formación para la investigación en políticas y sistemas de salud. Había pocos cursos en Europa Central y Oriental, Oriente Medio, el Norte de África y América Latina. La mayoría de los cursos (116/152) se impartían en inglés. El apoyo institucional para los cursos solía ser escaso y muchas instituciones carecían de la cantidad básica de individuos formados necesarios para dar apoyo a los estudiantes de doctorado y posdoctorado. Apenas había coherencia entre las instituciones en cuanto a la definición de las competencias necesarias para la investigación en políticas y sistemas de salud. La colaboración entre las disciplinas para ofrecer la variedad de perspectivas metodológicas necesarias no fue suficiente. Asimismo, la falta de alternativas a la formación in situ puede imposibilitar la asistencia de determinado público estudiantil, como responsables políticos.La formación para la investigación en políticas y sistemas de salud es importante para mejorar la capacidad local para dirigir una investigación de calidad en este campo. Se ofrecen seis recomendaciones para mejorar el contenido, la accesibilidad y el alcance de la formación. Primero, crear un repositorio de información sobre los cursos. Segundo, establecer redes para dar apoyo a la formación. Tercero, definir las competencias con respecto a la investigación en políticas y sistemas de salud. Cuarto, fomentar la colaboración multidisciplinar. Quinto, ampliar la cobertura geográfica y lingüística de los cursos. Por último, considerar formatos de enseñanza alternativos.استقصاء خصائص التدريب على إعداد أبحاث عن السياسات والنظم الصحية حول العالم وتحديد التوصيات الواجب اتباعها بشأن التحسين والتوسع.قمنا بتحديد المؤسسات التي تقدم التدريب على إعداد أبحاث عن السياسات والنظم الصحية في جميع أنحاء العالم. وفي عام 2014، قمنا بانتداب بعض المشاركين من المؤسسات التي تم تحديدها للمشاركة في استطلاع للرأي عبر الإنترنت عن خصائص المؤسسات والبرامج التدريبية المقدمة. تم استكشاف نتائج استطلاع الرأي أثناء إجراء مقابلات متعمقة مع مجموعة محددة من المبلّغين الرئيسيين.ساهمت الدراسة في الوقوف على العديد من الفجوات الرئيسية في التدريب على إعداد الأبحاث عن السياسات والنظم الصحية. كان هناك القليل من البرامج التدريبية في وسط وشرق أوروبا، أو الشرق الأوسط، أو شمال أفريقيا، أو أمريكا اللاتينية. وكان يتم تدريس معظم البرامج التدريبية (بواقع 116 دورة من إجمالي 152) باللغة الإنجليزية. وكان الدعم المؤسسي للبرامج التدريبية غائبًا في أغلب الأحوال، كما كانت العديد من المؤسسات تفتقر بدورها إلى العدد المطلوب من الأفراد المُدَرّبين اللازمين لدعم طلاب مرحلة الدكتوراه والمرحلة اللاحقة عليها. كان هناك القليل من التجانس بين المؤسسات في وضع تعريفات للكفاءات المطلوبة لإعداد الأبحاث عن السياسات والنظم الصحية. وكان التعاون في مختلف الاختصاصات لتوفير نطاق وجهات النظر المنهجية اللازمة لهذا الشأن غير كافٍ. وعلاوة على ذلك، قد يؤدي عدم وجود بدائل للتعليم الميداني إلى إثناء بعض الفئات المعينة من المتدربين مثل صنّاع السياسات.إن التدريب في مجال إعداد الأبحاث عن السياسات والنظم الصحية مهم لتحسين القدرات المحلية على إجراء بحث نوعي في هذا المجال. ونحن نقدم ست توصيات لتحسين محتوى التدريب وإتاحته وتيسير سبل الحصول عليه. أولاً، إنشاء مستودع المعلومات المتعلق بالبرامج التدريبية. ثانيًا، تأسيس الشبكات لدعم التدريب. ثالثًا، وضع تعريف للكفاءات في مجال إعداد الأبحاث عن السياسات والنظم الصحية. رابعًا، تشجيع التعاون بين الاختصاصات المتعددة. خامسًا، توسيع نطاق التغطية الجغرافية واللغوية للبرامج التدريبية. وأخيرًا، التفكير في تطبيق صيغ تعليم بديلة.旨在调查全球范围内卫生政策和体系研究培训的特征，以确定改进和扩展建议。.我们确定了在全球范围内提供卫生政策和体系研究培训的机构。 2014 年，我们针对这些机构及其提供课程的特征开展了一项在线调查，并从这些机构招募了相关人员参与调查。 通过对选定的重要知情人进行深入访问，发掘调查结果。.本调查研究发现了一些卫生政策和体系研究培训中存在的重大差距。 中欧和东欧、中东、北非或者拉丁美洲的课程开设不足。 大多数 (116/152) 课程采用英语授课。 课程常常缺乏制度支持，许多机构缺乏经过培训的教员以指导博士生和博士后学员。 机构间对卫生政策和体系研究培训所需能力的定义不一致。 跨学科合作不足，无法为研究课题提供所需的方法论视角范围。 此外，单一的现场授课方式导致某些学员（例如政策制定者）无法参与。.卫生政策和体系研究培训对于提升当地在该领域开展质量研究的能力方面至关重要。 我们提供了六项建议，以改进培训内容、提高培训可得性，同时扩大培训范围。 首先，创建一个课程信息库。 第二，建立培训支持网络。 第三，明确卫生政策和体系研究的能力要求。 第四，鼓励多学科合作。 第五，扩大课程的地域和语言覆盖面。 最后，考虑其他教学方式。.Изучить особенности подготовки научных кадров по вопросам политики в области здравоохранения и систем здравоохранения в мире и определить рекомендуемые действия для ее улучшения и расширения охвата.Были выявлены учреждения, занимающиеся подготовкой научных кадров по вопросам политики в области здравоохранения и систем здравоохранения в разных странах мира. В 2014 году из выявленных учреждений были набраны участники для прохождения электронного опроса, цель которого заключалась в определении особенностей учреждений и преподаваемых курсов. Результаты опроса были проанализированы в ходе содержательных интервью с отдельными ключевыми информаторами.В результате исследования было выявлено несколько существенных пробелов в подготовке научных кадров по вопросам политики в области здравоохранения и систем здравоохранения. Небольшое количество курсов преподавались в странах Центральной и Восточной Европы, Среднего Востока, Северной Африки или Латинской Америки. Большинство (116 из 152) курсов преподавались на английском языке. Институциональная поддержка курсов часто отсутствовала, и во многих учреждениях наблюдался недостаток обученных лиц, необходимых для эффективного руководства аспирантами и докторантами. Разные учреждения имели разное понимание компетенции, необходимой для проведения исследований, касающихся политики в области здравоохранения и систем здравоохранения. Междисциплинарное сотрудничество для представления разнообразных методологических перспектив, необходимое в этой сфере, проводилось в недостаточном объеме. Кроме того, безальтернативность очного обучения может лишить возможности участия в обучении определенных категорий потенциальных студентов, например лиц, ответственных за разработку политики.Подготовка научных кадров по вопросам политики в области здравоохранения и систем здравоохранения необходима для наращивания местного потенциала, чтобы обеспечить возможность проведения исследований в этой сфере. Авторы приводят шесть рекомендаций, нацеленных на улучшение содержания, доступности и охвата подготовки. Во-первых, необходимо создать архив информации о курсах. Во-вторых, необходимо установить связи между учреждениями для содействия обучению. В-третьих, необходимо дать определение компетенции применительно к исследованиям, касающимся политики в области здравоохранения и систем здравоохранения. В-четвертых, необходимо поощрять междисциплинарное сотрудничество. В-пятых, необходимо расширить географический и языковой охват курсов. Наконец, необходимо предоставить возможность альтернативных форм обучения.