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Malawi has a long history of receiving foreign aid, both monetary and technical support, for its health and other services provision. In the past two decades, foreign aid has increased, with the aim of the country being able to achieve its Millennium Development Goals by the end of 2015. It is currently moving towards achieving the sustainable development goals. Despite increased donor support, progress in the Malawian health service has remained very slow. This article discusses how trusting relationships amongst the stakeholders is vital in proper financial management, including of foreign aid and effective functioning of the health system in Malawi. This article is based on a qualitative study, using a range of research approaches: the in-depth case study of foreign aid funded Maternal and Child Health (MCH) projects (n = 4); Key Informant Interviews (n = 20) and reviews of policy documents to explore the issues around foreign aid and MCH services in Malawi. During the study period 2014-16, the country continued to face significant financial and other resource management challenges. The study has identified key factors, notably the issue of financial mismanagement, particularly Cashgate, news of which broke in 2013. This scandal has resulted in a great deal of mistrust amongst key stakeholders in health. The concomitant deterioration of working relationships has had a major impact on the health system resulting in further mal-distribution of resources and programme duplications. After highlighting key issues around foreign aid, Cashgate and trusting relationships amongst stakeholders, this article makes policy suggestions, with the aim of assisting donors and external development partners to better understand Malawian socio-political networks and relationships amongst key stakeholders. This understanding will help all those involved in the effective financial management and dispersal of foreign aid.

Background Africa’s involvement in clinical trials remains very low. Although the crucial role of training initiatives in building clinical trial capacity in Africa has been documented, current efforts fall short as they lack alignment with local contexts. This study aimed to design, develop, implement, and evaluate an innovative clinical trial operations training program for Africa. Methods We developed ClinOps, a novel 10-week clinical trial operations training program for study coordinators in Africa to enhance their expertise in four fundamental areas: designing, conducting, managing, and reporting clinical trials. To streamline the learning process, we used cloud-based applications that minimize the need for software installations while maximizing student engagement. VoiceThread facilitated interactive content that could be accessed offline. Moodle, an open-source learning management system, offered a platform for sharing learning tools, mentorship, and rubric-driven competency assessments, including quizzes, forums, tutorials, and group assignments. We utilized Zoom for live tutorials and mentoring as required. Effectiveness of the program was evaluated through quantitative pre- and post-surveys, qualitative end-course evaluations, and a comprehensive monitoring and evaluation framework. The pre- and post-surveys measured changes in trainees’ confidence in clinical trial domains and leadership and coordination skills. End-course evaluations gathered feedback on the course content, organization, technology, and instructional methods. We used Wilcoxon rank test to analyze pre- and post-survey scores and thematic analysis to analyze the qualitative data. Results In the initial cohort, 88 study coordinators from 19 countries participated, including 56 (64%) females, with 57 (65%) actively employed as study coordinators during the training, and 85 (97%) possessing prior experience in clinical trial roles. Among these, 71 (81%) successfully completed the course, with 69 (97%) also completing the post-course assessment. Post-training scores demonstrated substantial improvement compared to pre-training scores in each competency area, including in designing (pre-post training median score = 3.6 vs. 4.6, median difference = 1.0, 95% CI 0.8–1.1, p  < 0.001), managing (pre-posttest median score = 3.4 vs. 4.2, median difference = 0.6, 95% CI 0.4–0.8, p  < 0.001), conducting (pre-post training median score = 3.9 vs. 4.7, median difference = 0.9, 95% CI 0.6-1.0, p  < 0.001), and reporting (pre-posttest median score = 3.0 vs. 4.5, median difference = 1.0, 95% CI 0.9–1.5, p  < 0.001) clinical trials. The monitoring and evaluation data confirm the program’s adherence to training best practices, including alignment with local priorities, country ownership, pedagogic innovation, institutional capacity building, sustainability, and ongoing partnerships. The end-course evaluation reflects participants’ positive feedback on the program’s structure, content, relevance to their current roles, and overall delivery methods. Conclusion The ClinOps program, designed by experts from academia and product development partners, enhanced participants’ clinical trial competencies. To effectively build clinical trials capacity on the continent, training programs should provide thorough competency development in designing, conducting, managing, and reporting trials.

Background National pharmacovigilance centres (national centres) are gradually gaining visibility as part of the healthcare delivery system in Africa. As does happen in high-income countries, it is assumed that national centres can play a central coordinating role in their national pharmacovigilance (PV) systems. However, there are no studies that have investigated whether national centres in Africa have sufficient organizational capacity to deliver on this mandate and previous studies have reported challenges such as lack of funding, political will and adequate human resources. We conducted interviews with strategic leaders in national centres in 18 African countries, to examine how they link the capacity of their organization to the outcomes of activities coordinated by their centres. Strategic leaders were asked to describe three situations in which activities conducted by their centre were deemed successful and unsuccessful. We analyzed these experiences for common themes and examined whether strategic leaders attributed particular types of resources and relationships with stakeholders to successful or unsuccessful activities. Results We found that strategic leaders most often attributed successful experiences to the acquisition of political (e.g. legal mandate) or technical (e.g. active surveillance database) resources, while unsuccessful experiences were often attributed to the lack of financial and human resources. Stakeholders that were most often mentioned in association with successful experiences were national government and development partners, whereas national government and public health programmes (PHPs) were often mentioned in unsuccessful experiences. All 18 centres, regardless of maturity of their PV systems had similar challenges. Conclusions The study concludes that national centres in Africa are faced with 3 core challenges: (1) over-reliance on development partners, (2) seeming indifference of national governments to provide support after national centres have gained membership of the World Health Organization (WHO) Programme for International Drug Monitoring (PIDM) and (3) engaging public health programmes in a sustainable way.

BackgroundGlobal Health Initiatives (GHI) have played an important role in shaping health outcomes in countries through disease- and intervention-focused investments. As key financing mechanisms, GHIs primarily support disease-specific efforts, but their investments have an important role in shaping national health systems.MethodsWe used the Health Systems Strengthening (HSS) Investments Database, available in the Primary Health Care for Global Health Initiatives Toolbox, to examine the budgeted contributions of Gavi and the Global Fund toward HSS in 32 countries, in the period 2007–2024. Investments were categorized across key health system categories: service delivery, health workforce, health products, health information systems, governance, financing, and advocacy. They were also disaggregated across the six World Health Organization Regions.ResultsThe majority (52%) of intended investments were classified as Health Workforce, including activities such as training, salary costs, and per diem. Service Delivery accounted for 21% of investments. However, there was heterogeneity in distribution across categories by the GHIs and across regions by each GHI.ConclusionsThis analysis raises a series of key questions that should be addressed to better understand GHI’s investments and more optimally leverage GHI funding to strengthen primary health care-oriented systems. Those relate to challenges in analyzing GHI funding data, alignment of funds across health systems activities, and use of investments to enhance country ownership and leadership. This series of questions encourages a transformative opportunity to build sustainable health systems in the context of post-donor transition.

Background Development Assistance for Health (DAH) represents an important source of health financing in many low and middle-income countries. However, there are few accounts on how priorities funded through DAH are integrated with district health priorities. This study is aimed at understanding the operational challenges of engaging development partners in district health planning in Tanzania. Methods This explanatory mixed-methods study was conducted in Kinondoni and Bahi districts, representing urban and rural settings of the country. Data collection took place between November and December 2015. The quantitative tools (mapping checklist, district questionnaire and Development partners (DPs) questionnaire) mapped the DPs and their activities and gauged the strength of DP engagement in district health planning. The qualitative tool, a semi-structured in-depth interview guide administered to 20 key informants (the council health planning team members and the development partners) explained the barriers and facilitators of engagement. Descriptive and thematic analysis was utilized for quantitative and qualitative data analysis respectively. Results Eighty-six per cent (85%) of the development partners delivering aid in the studied districts were Non-Governmental Organizations. Twenty percent (20%) of the interventions were HIV/AIDS interventions. We found that only four (4) representing 25 % (25%) DPs had an MOU with the District Council, 56 % (56%) had submitted their plans in writing to be integrated into the 2014/15 CCHP. Six (6) representing 38 % (38%) respondents had received at least one document (guidelines, policies and other planning tools) from the district for them to use in developing their organization activity plans. Eighty-seven point 5 % (87.5%) from Bahi had partial or substantial participation, in the planning process while sixty-two point 5 % (62.5%) from Kinondoni had not participated at all (zero participation). The operational challenges to engagements included differences in planning cycles between the government and donors, uncertainties in funding from the prime donors, lack of transparency, limited skills of district planning teams, technical practicalities on planning tools and processes, inadequate knowledge on planning guidelines among DPs and, poor donor coordination at the district level. Conclusions We found low engagement of Development Partners in planning. To be resolved are operational challenges related to differences in planning cycles, articulations and communication of local priorities, donor coordination, and technical skills on planning and stakeholder engagement.

The Ministry of Health and Family Welfare (MOHFW) of the Government of Bangladesh embarked on a sector-wide approach (SWAp) modality for the health, nutrition and population (HNP) sector in 1998. This programmatic shift initiated a different set of planning disciplines and practices along with institutional changes in the MOHFW. Over the years, the SWAp modality has evolved in Bangladesh as the MOHFW has learnt from its implementation and refined the program design. This article explores the progress made, both in terms of achievement of health outcomes and systems strengthening results, since the implementation of the SWAp for Bangladesh’s health sector. Secondary analyses of survey data from 1993 to 2011 as well as a literature review of published and grey literature on health SWAp in Bangladesh was conducted for this assessment. Results of the assessment indicate that the MOHFW made substantial progress in health outcomes and health systems strengthening. SWAps facilitated the alignment of funding and technical support around national priorities, and improved the government’s role in program design as well as in implementation and development partner coordination. Notable systemic improvements have taken place in the country systems with regards to monitoring and evaluation, procurement and service provision, which have improved functionality of health facilities to provide essential care. Implementation of the SWAp has, therefore, contributed to an accelerated improvement in key health outcomes in Bangladesh over the last 15 years. The health SWAp in Bangladesh offers an example of a successful adaptation of such an approach in a complex administrative structure. Based on the lessons learned from SWAp implementation in Bangladesh, the MOHFW needs to play a stronger stewardship and regulatory role to reap the full benefits of a SWAp in its subsequent programming. Le ministère de la Santé et des Affaires Familiales du Gouvernement du Bangladesh (MOHFW) s’est lancé) en 1988 dans une approche sectorielle (SWAp) pour la santé, la nutrition et les populations (HNP). Cette réorientation de programme a généré des disciplines et des pratiques de planification différentes, ainsi que des changements institutionnels dans le MOHFW. Au cours des années, la démarche du SWAp a évolué au Bangladesh, alors que le Ministère a tiré des leçons de sa mise en œuvre, et affiné la conception du programme. Cet article explore les progrès réalisés, à la fois en termes d’atteinte des objectifs de santé, et de mise en place de systèmes destinés à améliorer les performances Depuis la mise en place du SWAp dans le secteur de la santé au Bangladesh. Cette évaluation a pu être faite grâce à des analyses secondaires des données de l’enquête réalisée de 1993 à 2011, ainsi qu’à l’examen des publications et de la documentation parallèle sur le SWAp au Bangladesh. Les conclusions de l’évaluation indiquent que le MOHFW a réalisé des progrès dans le traitement des problématiques de santé et le renforcement des systèmes de santé. Les Swap ont favorisé l’harmonisation des aides financières et techniques autour des priorités nationales. Ils ont amélioré le rôle du gouvernement dans l’élaboration des programmes, et dans la mise en œuvre et la coordination d’un partenariat. Les systèmes du pays ont connu des améliorations structurelles tant dans le domaine de la supervision et l’évaluation que, les achats et les prestations de service, qui ont amélioré le fonctionnement des services de santé dans les soins essentiels. La mise en œuvre des SWAp a contribué par conséquent à accélérer les progrès sanitaires au Bangladesh durant ces 15 dernières années. Le SWAp de la santé au Bangladesh offre un exemple d’adaptation réussie d’une telle approche dans une structure administrative complexe. A partir des leçons apprises de la mise en place des SWAP au Bangladesh, le MOHFW doit jouer un rôle plus important en terme de leadership et en matière de règlementation, pour récolter tous les bénéfices d’un SWAp en vue des programmes futurs. El Ministerio de Salud y Bienestar Familiar (MSBF) del Gobierno de Bangladesh se embarcó en la modalidad de un enfoque de todo el sector (ETS) para la salud, la nutrición y la población (SNP) en 1998. Este cambio programático inició un conjunto diferente de disciplinas de planeación y prácticas junto con los cambios institucionales en el MSBF. Con los años, la modalidad de ETS ha evolucionado en Bangladesh a medida que el MSBF ha aprendido de su aplicación y refinado el diseño del programa. Este artículo explora los progresos realizados, tanto en términos de logros de los resultados de la salud como en los resultados del fortalecimiento de los sistemas, desde la aplicación del ETS para el sector de la salud de Bangladesh. El análisis secundario de los datos de la encuesta 1993-2011, así como una revisión de la literatura publicada y gris sobre el ETS de la salud en Bangladesh se llevó a cabo para esta evaluación. Los resultados de la evaluación indican que el MSBF hizo un progreso sustancial en los resultados de salud y en el fortalecimiento de los sistemas de salud. El ETS facilitó la alineación de los fondos y el apoyo técnico en torno a las prioridades nacionales, y mejoró el papel del gobierno en el diseño de programas, así como también en la implementación y desarrollo de la coordinación entre los socios. Las mejoras sistemáticas han tenido lugar en los sistemas del país con miras a monitorear y evaluar, procurar y suministrar servicios, que han mejorado la funcionalidad de los servicios de salud para proporcionar el cuidado esencial. La implementación de ETS ha contribuido, por lo tanto, a una mejoría acelerada en los resultados claves de la salud en Bangladesh en los últimos 15 años. El ETS de la salud en Bangladesh ofrece un ejemplo de una adaptación exitosa de un enfoque en una compleja estructura administrativa. Con base en las lecciones aprendidas de la implementación de ETS en Bangladesh, el MSBF necesita jugar un papel administrador y regulador para cosechar los beneficios completos en su programación posterior. 孟加拉政府的医疗和家庭福利部 （MOHFW） 从 1998 年开始 对医疗、营养、人口领域 （HNP） 开展了全部门研究 （SWAp） 。 这个项目伴随着MOHFW的制度变化促进了一些 不同的规划准则和实践。这些年中, 全部门方法不断改进, 因 为MOHFW 从实施中不断学习并修改项目设计。本文探索在 孟加拉医疗领域实施SWAp以来取得的健康结果和系统加强 结果。为了进行评估, 我们对 1993 年到 2011 年调查数据进 行二级分析, 并对关于孟加拉SWAp发表的文章和非正式出版 的文章进行文献回顾。评估结果显示, MOHFW在医疗和体系 方面都取得了显著进步。SWAp 促进了资金和技术支持方面 的优先, 加强了政府在项目设计和实施中的角色, 以及发展伙 伴的协调。在医疗体系中也有系统性加强, 比如监督评估、 采购和提供治疗, 这些都加强了医疗机构提供基础服务的能 力。SWAp 的实施在过去 15 年中对孟加拉关键医疗结果的提 高做出了贡献。孟加拉 SWAp 的实施是在复杂的行政结构下 成功实施的一个案例。基于从孟加拉 SWAp 中得到的经验, 在接下来的项目中想要获得更全面的收益, MOHFW 需要充 当一个更强有力的管理和规范者的角色

Building on the gains of the National Health Mission, India’s Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) Strategy, launched in 2013, was a milestone in the country’s health planning. The strategy recognised the interdependence of RMNCH+A Interventions across the life stages and adopted a comprehensive approach to address inequitable distribution of healthcare services for the vulnerable population groups and in poor-performing geographies of the country. Based on innovative approaches and management reforms, like selection of poor-performing districts, prioritisation of high-impact RMNCH+A healthcare interventions, engagement of development partners and institutionalising a concurrent monitoring system the strategy strived to improve efficiency and effectiveness within the public healthcare delivery system of the country. 184 High Priority Districts were identified across the country on a defined set of indicators for implementation of critical RMNCH+A Interventions and a dedicated institutional framework comprising National and State RMNCH+A Units and District Level Monitors supported by the development partners was established to provide technical support to the state and district health departments. Health facilities based on case load and available services across the High Priority Districts were prioritised for strengthening and were monitored by an RMNCH+A Supportive Supervision mechanism to track progress and generate evidence to facilitate actions for strengthening ongoing interventions. The strategy helped develop an integrated systems-based approach to address public health challenges through a comprehensive framework, defined priorities and robust partnerships with the partner agencies. However, lack of a robust monitoring and evaluation framework and sub-optimal focus on social determinants of health possibly limited its overall impact and ability to sustain improvements. Guided by the learnings and limitations, the Government of India has now designed the ‘Aspirational Districts Program’ to holistically address health challenges in poor-performing districts within the overall sociocultural domain to ensure inclusive and sustained improvements.

This study reviews the experience of cooperation in selected international river basins and during selected time periods in those basins. The review is from a country perspective and focuses on the countries' perceived risks and opportunities in engaging in regional cooperation deals in response to the prospects for cooperation. It is primarily aimed at external development partners who promote regional public goods (river basin institutions and agreements) and support cooperative activities and investments in international waters. We also believe that countries and individuals engaged in international waters issues will find this study and reflections helpful in enhancing their knowledge and advancing their actions with respect to regional cooperation. The specific purpose of the study is to alert teams engaged in promoting cooperation in international waters to the need for a careful risk analysis and for the formulation of a risk reduction strategy to help countries move toward cooperation.

Studies on international development partners’ assistance to electoral management bodies (EMBs) in the conduct of elections in the world have demonstrated that it is characterised by a myriad of constraints and impacts. This phenomenon has only received a broad-brush overview in the literature, leaving unscratched, unexplored areas in the body of literature, especially in developing countries like Nigeria. This paper analysed these areas of the international development partners’assistance to Nigeria’s Independent National Electoral Commission (INEC) in the 2011 and 2015 elections. The paper made an important contribution to the literature on international development partners’assistance to electoral management bodies, particularly Nigeria’s INEC as it demonstrated that the modusoperandi of these supports to INEC has not manifested in a highly effective electoral management institution. Some of the unexplored areas that constitute problems are the international agencies’ support to only INEC, with less emphasis on other stakeholders, and their inability to control corruption within the electoral commission. Furthermore, the assistance is yet to improve the INEC’s handling of transportation, technological and language difficulties that the commission is confronted withduring elections in Nigeria. The paper employed a secondary source of data collection and used a qualitative method of data analysis. For a free and fair electoral administration in the country, the paper proposed a more expanded role for the donor agencies in the course of their support to INEC to assuage the yearnings of grassroots citizens and other non-INEC stakeholders in Nigeria.

Major development projects in many African countries are often financed by development partners through development aid procurement. Development partners implement specific procurement policies aimed at promoting development in countries receiving aid. This article examines the policies of development partners applicable to aid funded procurement. It argues that some development partner policies could limit the policy space available to implement prioritized development goals domestically.