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The overview summarizes the evaluation of community responses (15 studies, including 11 evaluations carried out in 8 countries). It presents the evaluation questions, the methodology, the key results achieved by community responses along the continuum of prevention, treatment, care and support, and the resulting policy and programmatic implications. Before the scale-up of the international response to the AIDS pandemic, community responses in developing countries played a crucial role in providing services and care for those affected. This study is the first comprehensive, mixed-method evaluation of the impact of that response. The evaluation finds that community response can be effective at increasing knowledge of HIV, promoting social empowerment, increasing access to and use of HIV services, and even decreasing HIV incidence, all through the effective mobilization of limited resources. By effectively engaging with this powerful community structure, future HIV and AIDS programs can ensure that communities continue to contribute to the global response to HIV and AIDS.

AIDS epidemics continue to threaten the livelihoods of millions of people in sub-Saharan Africa. Three decades after the disease was first recognized, the annual death toll from AIDS exceeds that from wars, famine and floods combined. Yet despite millions of dollars of aid and research, there has previously been little detailed on-the-ground analysis of the multifaceted impacts on rural people. Filling that gap, this book brings together recent evidence of AIDS impacts on rural households, livelihoods, and agricultural practice in sub-Saharan Africa. There is particular emphasis on the role of women in affected households, and on the situation of children. The book is unique in presenting micro-level information collected by original empirical research in a range of African countries, and showing how well-grounded conclusions on trends, impacts and local responses can be applied to the design of HIV-responsive policies and programmes. AIDS impacts are more diverse than we previously thought, and local responses more varied - sometimes innovative, sometimes desperate. The book represents a major contribution to our understanding of the impacts of AIDS in the epidemic's heartland, and how these can be managed at different levels.

Health systems in Sub-Saharan Africa have changed profoundly over the last 20 years. The economic crisis of the 1980s and 1990s rattled public health care systems, which were largely holdovers from the colonial and postcolonial eras. The later wave of structural adjustments and public sector reforms wrought further change. As African economies opened to market based approaches, the private sector became a sizable source of health care service. Today about half the health expenditures in Africa are private, and private providers play a major role in the delivery of outpatient services. This is draws on the lessons, knowledge, and data gathered by the World Bank's Africa Region Human Resources for Health Program. For the first time, the various complexities of Human Resources for Health (HRH) labor markets are addressed comprehensively in one volume. Given the increasing demand in countries for strong health workforces that can help achieve universal health coverage; we hope this book will be beneficial to researchers, policy makers, and practitioners who are trying to develop evidence-based HRH interventions to achieve this end.

To provide cost guidance for developing a locally adaptable and nationally scalable community health worker (CHW) system within primary-health-care systems in sub-Saharan Africa. The yearly costs of training, equipping and deploying CHWs throughout rural sub-Saharan Africa were calculated using data from the literature and from the Millennium Villages Project. Model assumptions were such as to allow national governments to adapt the CHW subsystem to national needs and to deploy an average of 1 CHW per 650 rural inhabitants by 2015. The CHW subsystem described was costed by employing geographic information system (GIS) data on population, urban extents, national and subnational disease prevalence, and unit costs (from the field for wages and commodities). The model is easily replicable and configurable. Countries can adapt it to local prices, wages, population density and disease burdens in different geographic areas. The average annual cost of deploying CHWs to service the entire sub-Saharan African rural population by 2015 would be approximately 2.6 billion (i.e. 2600 million) United States dollars (US$). This sum, to be covered both by national governments and by donor partners, translates into US$ 6.86 per year per inhabitant covered by the CHW subsystem and into US$ 2.72 per year per inhabitant. Alternatively, it would take an annual average of US$ 3750 to train, equip and support each CHW. Comprehensive CHW subsystems can be deployed across sub-Saharan Africa at cost that is modest compared with the projected costs of the primary-health-care system. Given their documented successes, they offer a strong complement to facility-based care in rural African settings.

Supportive supervision is an important element of community health worker (CHW) programmes and is believed to improve CHW motivation and performance. A group supervision intervention, which included training and mentorship of supervisors, was implemented in Ethiopia, Kenya, Malawi and Mozambique. In three of the countries, this was combined with individual and/or peer supervision. A mixed-methods implementation study was conducted to assess the effect of the supervision intervention on CHWs’perceptions of supervision and CHW motivation-related outcomes. In total, 153 in-depth interviews were conducted with CHWs, their supervisors and managers. In addition, questionnaires assessing perceived supervision and motivation-related outcomes (organizational and community commitment, job satisfaction and conscientiousness) were administered to a total of 278 CHWs pre-and post-intervention, and again after 1 year. Interview transcripts were thematically analysed using a coding framework. Changes in perceived supervision and motivation-related outcomes were assessed using Friedman’s ANOVA and post hoc Wilcoxon signed-rank tests. Interview participants reported that the supervision intervention improved CHW motivation. In contrast, the quantitative survey found no significant changes for measures of perceived supervision and inconsistent changes in motivation-related outcomes. With regard to the process of supervision, the problem-solving focus, the sense of joint responsibilities and team work, cross-learning and skill sharing, as well as the facilitating and coaching role of the supervisor, were valued. The empowerment and participation of supervisees in decision making also emerged in the analysis, albeit to a lesser extent. Although qualitative and quantitative findings differed, which could be related to the slightly different focus of methods used and a ‘ceiling effect’ limiting the detection of observable differences from the survey, the study suggests that there is potential for integrating supportive group supervision models in CHW programmes. A combination of group with individual or peer supervision, preferably accompanied with methods that assess CHW performance and corresponding feedback systems, could yield improved motivation and performance. La supervision d’appoint est un élément important des programmes concernant les agents de santé communautaires (ASC) et on estime qu’elle renforce la motivation et la performance des ASC. Une intervention de supervision de groupe, associant la formation et l’encadrement des superviseurs, a été mise en œuvre en Éthiopie, au Kenya, au Malawi et au Mozambique. Dans trois des pays, elle a été associée à une évaluation individuelle et/ou par les pairs. Une étude sur la mise en œuvre de méthodes mixtes a été réalisée dans le but d’évaluer l’incidence de l’intervention de supervision sur la manière dont les ASC perçoivent le contrôle ainsi que les résultats liés à leur degré de motivation. Au total, 153 entretiens en profondeur ont été réalisés avec des ASC, leurs superviseurs et leurs hauts dirigeants. D’autre part, des questionnaires ont été administrés à un total de 278 ASC avant et après l’intervention, - et à nouveau un an plus tard -, dans le but d’évaluer la perception des résultats en matière de supervision et de motivation (engagement organisationnel et communautaire, satisfaction au travail et conscience professionnelle). On a procédé à l’analyse thématique des transcriptions des entrevues à l’aide d’une grille de codage. Les changements observés dans les résultats relatifs à la supervision et à la motivation ont été évalués à l’aide de l’analyse de variance (ANOVA) de Friedman et des tests post hoc de Wilcoxon. Les participants aux entrevues ont déclaré que l’intervention de supervision a amélioré la motivation des ASC. En revanche, l’enquête quantitative n’a révélé aucun changement significatif dans les mesures de la supervision, ni de changements incohérents dans les résultats liés à la motivation. En ce qui concerne le processus de supervision, l’accent mis sur la résolution des problèmes, le sens des responsabilités communes et le travail d’équipe, l’interapprentissage et le partage des compétences, ainsi que le rôle de facilitateur et d’encadreur du superviseur, ont été appréciés. L’analyse a également mis en lumière le degré d’autonomisation et de participation des personnes encadrées à la prise de décision, quoique dans une moindre mesure. Bien que les résultats qualitatifs et quantitatifs diffèrent, ce qui pourrait être lié à l’orientation légèrement différente des méthodes utilisées et à un “effet plafond” limitant la détection des différences observables à partir de l’enquête, l’étude suggère qu’il existe un potentiel permettant d’intégrer des modèles de supervision d’appoint pour les groupes dans les programmes des relais communautaires. L’association d’une évaluation individuelle ou par les pairs, accompagnée de préférence de méthodes d’évaluation de la performance des ASC et des systèmes de contrôle correspondants, peut entraîner une amélioration de la motivation et de la performance. 支持性督导是社区卫生工作者（CHW）项目的重要要素, 被 认为可激励CHW, 改善其工作表现。在埃塞俄比亚、肯尼 亚、马拉维和莫桑比克进行了一项分组督导干预, 包括培训和 督导员指导。在其中三个国家还结合了个人和/或同伴督导。 我们进行了一项混合方法执行研究, 评估督导干预后, CHW对 督导的观感变化和CHW动力相关的结局。共对CHW、CHW 督导员和管理者进行了153次深度访谈。此外, 在干预前、干 预后和1年后采用问卷评估了278名CHW感受的督导情况和这 些CHW的动力相关结局（对组织和社区的投入程度、工作满 意度和工作态度）。采用编码框架对访谈文本进行主题分 析。采用Friedman ANOVA和Wilcoxon符号秩检验分析感受 督导情况和动力相关结局的变化。受访者表示督导干预激励 了CHW。但是, 定量调查未发现感受督导情况有显著变化, 而 动力相关结局的变化不稳定。在督导过程中, 被看重的因素是 对解决问题的关注、集体责任感和团队合作、交叉学习和技 能分享, 以及督导员的协助和指导功能。研究还显示CHW重 视赋权和参与决策过程, 虽然程度较低。定性和定量的发现不 一致, 可能是由于两种方法的侧重略有不同, 且调查方法可能 存在“天花板效应”, 限制了观察结果的差异。尽管如此, 本研 究显示了在CHW项目中整合支持性小组督导的潜在效果。结 合小组督导和个人或同伴督导, 在理想情况下辅以CHW绩效 评估和反馈制度, 可更好地激励CHW, 改善其绩效。 ¿La supervisión comprensiva mejora la motivación de los trabajadores comunitarios de salud? Un estudio de métodos mixtos en cuatro países africanos La supervisión comprensiva es un importante elemento de los programas de trabajadores comunitarios de salud (TCS) y se cree que mejora la motivación y desempeño de los TCS. Una intervención de supervisión de grupo, que incluyó el entrenamiento y orientación de supervisores, se implementó en Etiopía, Kenia, Malawi y Mozambique. En tres países, esto se combinó con supervisión individual y/o de pares. Un estudio de implementación de métodos mixtos fue llevado a cabo para evaluar el efecto de la intervención de supervisión en las percepciones de los TCS sobre la supervisión y resultados relacionados con la motivación de los TCS. En total, se llevaron a cabo 153 entrevistas en profundidad con TCS, sus supervisores y directores. Adicionalmente, cuestionarios evaluando las percepciones de supervisión y resultados relacionados con la motivación (compromiso de la organización y de la comunidad, satisfacción en el trabajo y diligencia) fueron administrados a un total de 278 TCS antes y después de la intervención, y un año más tarde. Transcripciones de las entrevistas fueron analizadas de manera temática usando un marco de codificación. Cambios en las percepciones de supervisión y resultados relacionados con la motivación fueron evaluados usando la prueba ANOVA de Friedman y la prueba post hoc de rangos con signo de Wilcoxon. Los participantes de las entrevistas reportaron que la intervención de supervisión mejoró la motivación de los TCS. En contraste, la encuesta cuantitativa no encontró cambios significativos en las medidas de supervisión percibida y encontró cambios inconsistentes en los resultados relacionados con la motivación. Con respecto al proceso de supervisión, el enfoque de resolución de problemas, el sentido de responsabilidades conjuntas y el trabajo en equipo, el aprendizaje mixto y las habilidades compartidas, así como el rol de facilitador y entrenador del supervisor, fueron valorados. El empoderamiento y la participación de los supervisados en la toma de decisiones también surgió en el análisis, hasta cierto punto. Aunque los hallazgos cualitativos y cuantitativos fueron diferentes, lo cual podría estar relacionado con los ligeramente diferentes enfoques de métodos usados y un ‘efecto techo’ que limita la detección de diferencias observables en la encuesta, el estudio indica que hay potencial para integrar modelos de supervisión comprensiva de grupo en los programas de TCS. Una combinación de supervisión de grupo e individual o de pares, preferiblemente acompañada con métodos para evaluar el desempeño de los TCS y correspondientes sistemas de retroalimentación, podrían mejorar la motivación y el desempeño.

[...]the report underscored the importance of integrating CHW subsystems into the next generation of primary health-care delivery.5 The UN's Broadband Commission, UNAIDS, Roll Back Malaria, and the MDG advocates are among the groups calling for a massive scaling up of CHWs in sub-Saharan Africa. [...]note that the scale-up of CHW programmes should not be restricted to low-income and middle-income countries.

Abstract Given the vast investments made in national immunization programmes (NIPs) and the significance of NIPs to public health, it is important to understand what influences the optimal performance of NIPs. It has been established that well-performing NIPs require enabling health systems. However, systematic evidence on how the performance of health systems impacts on NIPs is lacking, especially from sub-Saharan Africa. We conducted a qualitative systematic review to synthesize the available evidence on health systems constraints and facilitators of NIPs in sub-Saharan Africa, using human papillomavirus immunization programmes as a proxy. Fifty-four articles published between 2008 and 2018 were found to be eligible. Data extraction was guided by an analytical model on the interface between NIPs and health systems. A cross-cutting thematic analysis of the extracted data was performed. This systematic review provides evidence necessary for informing ongoing health systems strengthening initiatives in sub-Saharan Africa. There is evidence to suggest that NIPs in sub-Saharan Africa have surmounted significant health systems constraints and have achieved notable public health success. This success can be attributed to strong political endorsement for vaccines, clear governance structures and effective collaboration with global partners. Despite this, significant health systems constraints persist in service delivery, vaccine communication, community engagement, the capacity of the health workforce and sustainable financing. These constraints could derail further progress if not addressed through health systems strengthening efforts. There is a need to expand the research agenda to include the comprehensive evaluation of health systems constraints and facilitators of NIPs within sub-Saharan Africa.

The conditions under which a mother gives birth greatly affect the health risk of both the mother and the child. This article addresses how local exposure to organized violence affects whether women give birth in a health facility. We combine geocoded data on violent events from the Uppsala Conflict Data Program with georeferenced survey data on the use of maternal health care services from the Demographic and Health Surveys. Our sample covers 569,201 births by 390,574 mothers in 31 countries in sub-Saharan Africa. We use a mother fixed-effects analysis to estimate the effect of recent organized violence events within a radius of 50 km of the home of each mother on the likelihood that her child is born in a health facility. The results indicate that geographical and temporal proximity to organized violence significantly reduces the likelihood of institutional births. Although the level of maternal health care overall is lower in rural areas, the negative effect of violence appears to be stronger in urban areas. The study further underscores the importance of household and individual resilience, indicating that the effect of organized violence on institutional child delivery is greater among poor and less-educated mothers.

Access to healthcare is one of the key global concerns as treasured in the Sustainable Development Goals. This study, therefore, sought to assess the individual and contextual factors associated with barriers to accessing healthcare among women in sub-Saharan Africa (SSA). Data for this study were obtained from the latest Demographic and Health Surveys (DHS) conducted between January 2010 and December 2018 across 24 countries in SSA. The sample comprised 307,611 women aged 15-49. Data were analysed with STATA version 14.2 using both descriptive and multilevel logistic regression modelling. Statistical significance was set at p<0.05. It was found that 61.5% of women in SSA face barriers in accessing healthcare. The predominant barriers were getting money needed for treatment (50.1%) and distance to health facility (37.3%). Women aged 35-39 (AOR = 0.945, CI: 0.911-0.980), married women (AOR = 0.694, CI: 0.658-0.732), richest women (AOR = 0.457, CI:0.443-0.472), and those who read newspaper or magazine at least once a week (AOR = 0.893, CI:0.811-0.983) had lower odds of facing barriers in accessing healthcare. However, those with no formal education (AOR = 1.803, CI:1.718-1.891), those in manual occupations (AOR = 1.551, CI: 1.424-1.689), those with parity 4 or more (AOR = 1.211, CI: 1.169-1.255), those who were not covered by health insurance (AOR = 1.284, CI: 1.248-1.322), and those in rural areas (AOR = 1.235, CI:1.209-1.26) had higher odds of facing barriers to healthcare access. Both individual and contextual factors are associated with barriers to healthcare accessibility in SSA. Particularly, age, marital status, employment, parity, health insurance coverage, exposure to mass media, wealth status and place of residence are associated with barriers to healthcare accessibility. These factors ought to be considered at the various countries in SSA to strengthen existing strategies and develop new interventions to help mitigate the barriers. Some of the SSA African countries can adopt successful programs in other parts of SSA to suit their context such as the National Health Insurance Scheme (NHIS) and the Community-based Health Planning and Services concepts in Ghana.

Background After neonatal conditions, the leading causes of child mortality in sub-Saharan Africa are malaria, lower respiratory infections, and dehydration. Many of these deaths could be averted with basic and widely-available health interventions, but quality of care remains low. We aimed to assess adherence to clinical guidelines for these conditions in Burundi, the Democratic Republic of the Congo (DRC), and Nigeria, and estimate the proportion of guideline non-adherence that is explained by gaps in health care provider knowledge versus other factors. Methods We conducted an observational study in randomly-sampled health facilities in each study country, linking data from direct observations of under-5 sick child visits, knowledge assessments of the treating health care providers, and interviews with caregivers. For children diagnosed with malaria, severe respiratory infection, or dehydration, we defined the “adherence gap” as the percentage who did not receive correct treatment, and the “know-do gap” as the percentage who received incorrect care despite the provider knowing the correct treatment. We evaluated the portions of overall adherence gaps that were explained by know-do gaps, and described factors associated with know-do gaps. Results A total of 2,212 sick child visits treated by 852 providers were analyzed. In the pooled sample, 87%, 75%, and 77% percent of providers were familiar with the main treatment recommendations for malaria, pneumonia, and dehydration, respectively. When observed by survey staff during consultations with sick children, compliance with the same guidelines was 76%, 74%, and 51%. Knowledge gaps explained between 0% of the total adherence gap for pneumonia treatment in Burundi and 40% of the gap for pneumonia treatment in the DRC. Conclusions To improve quality of care, it is critical to understand why providers do not consistently follow clinical guidelines. Our findings suggest that adherence to protocols is low, but that knowledge is not the primary barrier. Interventions to improve quality must go beyond improving knowledge to also address other drivers of provider behavior such as motivation, workload, and systemic constraints.