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Health systems across Africa are in urgent need of improvement. The public sector should not be expected to shoulder the burden of directly providing the needed services alone, nor can it, given the current realities of African health systems. Therefore to achieve necessary improvements, governments will need to rely more heavily on the private health sector. Indeed, private providers already play a significant role in the health sector in Africa and are expected to continue to play a key role, and private providers serve all income levels across sub- Saharan Africa's health systems. The World Health Organization (WHO) and others have identified improvements in the way governments interact with and make use of their private health sectors as one of the key ingredients to health systems improvements. Across the African region, many ministries of health are actively seeking to increase the contributions of the private health sector. However, relatively little is known about the details of engagement; that is, the roles and responsibilities of the players, and what works and what does not. A better understanding of the ways that governments and the private health sector work together and can work together more effectively is needed. This Report assesses and compares the ways in which African governments are engaging with their private health sectors. Engagement is defined, for the purposes of this report, to mean the deliberate, systematic collaboration of the government and the private health sector according to national health priorities, beyond individual interventions and programs. With effective engagement, one of the main constraints to better private sector contributions can be addressed, which in turn should improve the performance of health systems overall.

Cash transfers (CTs) are now high on the agenda of most governments in low-and middle-income countries. Within the field of health promotion, CTs constitute a healthy public policy initiative as they have the potential to address the social determinants of health (SDoH) and health inequalities. A systematic review was conducted to synthesise the evidence on CTs’impacts on SDoH and health inequalities in sub-Saharan Africa, and to identify the barriers and facilitators of effective CTs. Twenty-one electronic databases and the websites of 14 key organizations were searched in addition to grey literature and hand searching of selected journals for quantitative and qualitative studies on CTs’impacts on SDoH and health outcomes. Out of 182 full texts screened for eligibility, 79 reports that reported findings from 53 studies were included in the final review. The studies were undertaken within 24 CTs comprising 11 unconditional CTs (UCTs), 8 conditional CTs (CCTs) and 5 combined UCTs and CCTs. The review found that CTs can be effective in tackling structural determinants of health such as financial poverty, education, household resilience, child labour, social capital and social cohesion, civic participation, and birth registration. The review further found that CTs modify intermediate determinants such as nutrition, dietary diversity, child deprivation, sexual risk behaviours, teen pregnancy and early marriage. In conjunction with their influence on SDoH, there is moderate evidence from the review that CTs impact on health and quality of life outcomes. The review also found many factors relating to intervention design features, macro-economic stability, household dynamics and community acceptance of programs that could influence the effectiveness of CTs. The external validity of the review findings is strong as the findings are largely consistent with those from Latin America. The findings thus provide useful insights to policy makers and managers and can be used to optimise CTs to reduce health inequalities. Les transferts de fonds (CT) figurent désormais parmi les priorités de la plupart des gouvernements des pays à revenu faible ou intermédiaire. Dans le domaine de la promotion de la santé, les CT constituent une saine initiative de politique publique puisqu’ils ont le potentiel de s’attaquer aux déterminants sociaux de la santé (DSS) et aux inégalités de santé. Une revue systématique a été réalisée dans le but de synthétiser les données sur les impacts des CT sur les inégalités de santé et les DSS en Afrique subsaharienne, et pour identifier les obstacles ainsi que les initiatives favorables à la mise en place de CT efficaces. Vingt et une bases de données électroniques et les sites Web de 14 organismes clés ont été consultés, en plus de la littérature grise et de la recherche manuelle de revues sélectionnées pour des études quantitatives et qualitatives sur les impacts des CT sur les DSS et les résultats de santé. Sur les 182 textes complets examinés pour leur recevabilité, 79 rapports présentant les résultats de 53 études ont été inclus dans l’examen final. Les études ont été menées dans le cadre de 24 transferts de fonds, à savoir, 11 transferts non conditionnels (UCT), 8 transferts conditionnels (CCT) ainsi que 5 UCT et CCT jumelés. L’étude a révélé que les CT peuvent être efficaces pour s’attaquer aux déterminants structurels de la santé tels que la pauvreté monétaire, l’éducation, la capacité de résilience des ménages, le travail des enfants, le capital social, la cohésion sociale, la participation civique et la déclaration des naissances. La revue a également révélé que les CT modifient les déterminants intermédiaires tels que la nutrition, la diversité alimentaire, le dénuement des enfants, les comportements sexuels à risque, la grossesse chez les adolescentes et les mariages précoces. En même temps que les transferts influent sur les DSS, des données de la revue tendent à prouver raisonnablement que les CT ont un impact sur la santé et la qualité de vie. La revue a également révélé de nombreux facteurs liés aux caractéristiques de conception de l’intervention, à la stabilité macroéconomique, à la dynamique des ménages et à l’acceptation par la collectivité des programmes susceptibles d’influer sur l’efficacité des CT. La validité externe des résultats de la revue est excellente, car les résultats sont en grande partie conformes à ceux de l’Amérique latine. Les résultats fournissent donc des indications utiles aux décideurs et aux gestionnaires et peuvent être utilisés pour optimiser les CT afin de réduire les inégalités en matière de santé. 现金转移支付 （CTs） 是目前许多中低收入国家政府的重要议 程。在健康促进领域, CTs是有利于健康的公共政策, 因为可 以影响健康的社会决定因素 （SDoH） 和健康不公平性。我们 进行了系统综述, 综合CTs对撒哈拉以南非洲地区SDoH和健康 不公平性的影响的证据, 寻找有效实施CTs的阻碍和促进因 素。检索21个电子数据库, 14个关键组织的网站, 检索灰色文 献, 手动检索选定的期刊, 查找关于CTs对SDoH和健康结局影 响的定量和定性研究。182篇文献进入全文筛选, 最终纳入79 篇文章, 报告了53个研究的发现。这些研究涉及24个CTs项目, 包括11个无条件CTs （UCTs）, 5个有条件CTs （CCTs） 和5个 UCTs与CCTs结合的项目。综述发现, CTs可有效影响健康的结 构决定因素, 例如贫困、教育、家庭恢复力、童工、社会资本 和社会凝聚力、公民参与, 以及出生登记。综述还发现, CTs 会改变中间决定因素, 例如营养、饮食多样性、儿童贫困、危 险性行为、青少年怀孕和早婚。除对SDoH的影响外, 本综述 还显示CTs对健康和生命结局质量的影响。综述还发现, 与干 预设计特征、宏观经济稳定性、家庭动态和社区接受程度相 关的许多因素会影响CTs的有效性。上述发现具有很强的外部 效度, 因为与拉丁美洲的研究发现大体上一致。本综述发现可 帮助决策者和管理者充分利用CTs来降低健康不平等。 Las transferencias en efectivo (TEs) están en una posición predominante en la agenda de la mayoría de los gobiernos de los países de ingresos bajos y medios. Dentro del campo de la promoción de la salud, las TEs constituyen una iniciativa de política pública saludable, ya que tienen el potencial para abordar los determinantes sociales de la salud (DSdS) y las desigualdades en la salud. Una revisión sistemática se realizó para sintetizar la evidencia de los impactos de las TEs sobre los DSdS y las desigualdades en el África sub-Sahariana, y para identificar las barreras y los facilitadores de las TEs efectivas. Se hicieron búsquedas en 21 bases de datos electrónicas y los sitios web de 14 organizaciones claves, en adición a la literatura gris y la búsqueda manual de revistas seleccionadas, para encontrar estudios cuantitativos y cualitativos sobre impactos de las TEs sobre los DSdS y sobre los resultados de salud. Además de 182 textos completos seleccionados como elegibles, 79 informes que informaron los resultados de 53 estudios se incluyeron en la revisión final. Los estudios se realizaron dentro de 24 TDs que comprenden 11 TEs incondicionales (TEIs), 8 TEs condicionales (TECs) y 5 TEls y TECs combinadas. La revisión encontró que las TDs pueden ser efectivas en la lucha contra los determinantes estructurales de la salud tales como la pobreza financiera, la educación, la capacidad de recuperación de los hogares, el trabajo infantil, el capital social y la cohesión social, la participación ciudadana, y el registro de nacimientos. La revisión encontró, además, que las TEs modifican los determinantes intermedios tales como la nutrición, la diversidad de la dieta, la privación del niño, los comportamientos sexuales de riesgo, el embarazo adolescente y el matrimonio precoz. En conjunción con su influencia en los DSdS, hay evidencia moderada del impacto de las TEs en los resultados de salud y calidad de vida. La revisión también encontró muchos factores relacionados con la intervención de las características de diseño, la estabilidad macroeconómica, la dinámica del hogar y la aceptación de la comunidad de programas que podrían influir en la eficacia de las TEs. La validez externa de los resultados de la revisión es fuerte ya que los hallazgos son ampliamente consistentes con los de América Latina. Los resultados proporcionan información útil a los formuladores de políticas y a los gestores y pueden ser usados para optimizar las TEs para reducir las desigualdades en salud.

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.

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.

Abstract Leadership is a critical component of a health system and may be particularly important in Sub-Saharan Africa, where clinicians take on significant management responsibilities. However, there has been little investment in strengthening leadership in this context, and evidence is limited on what leadership capabilities are most important or how effective different leadership development models are. This scoping review design used Arksey and O’Malley’s approach of identifying the question and relevant studies, selection, charting of data, summarizing of results and consultation. A comprehensive search strategy was used that included published and unpublished primary studies and reviews. Seven databases were searched, and papers written in English and French between 1979 and 2019 were included. Potential sources were screened against inclusion and exclusion criteria. Data were grouped into common categories and summarized in tables; categories included conceptual approach to leadership; design of intervention; evaluation method; evidence of effectiveness; and implementation lessons. The findings were then analysed in the context of the review question and objectives. Twenty-eight studies were included in the review out of a total of 495 that were initially identified. The studies covered 23 of the 46 countries in Sub-Saharan Africa. The leadership development programmes (LDPs) described were diverse in their design. No consistency was found in the conceptual approaches they adopted. The evaluation methods were also heterogeneous and often of poor quality. The review showed how rapidly leadership has emerged as a topic of interest in health care in Sub-Saharan Africa. Further research on this subject is needed, in particular in strengthening the conceptual and competency frameworks for leadership in this context, which would also inform better evaluation. Our findings support the need for LDPs to be accredited, better integrated into existing systems and to put greater emphasis on institutionalization and financial sustainability from their early development.

Several countries in sub-Saharan Africa have recently adopted policies that remove user fees for facility-based delivery services. There is little rigorous evidence of the impact of these policies on utilization of delivery services and no evaluations have examined effects on neonatal mortality rates (NMR). In this article, we estimate the causal effect of removing user fees on the proportion of births delivered in facilities, the proportion of births delivered by Caesarean section, and NMR. We used data from Demographic and Health Surveys conducted in 10 African countries between 1997 and 2012. Kenya, Ghana and Senegal adopted policies removing user fees for facility-based deliveries between 2003 and 2007, while seven other countries not changing user fee policies were used as controls. We used a difference-in-differences (DD) regression approach to control for secular trends in the outcomes that are common across countries and for time invariant differences between countries. According to covariate-adjusted DD models, the policy change was consistent with an increase of 3.1 facility-based deliveries per 100 live births (95% confidence interval (CI): 0.9, 5.2) and an estimated reduction of 2.9 neonatal deaths per 1000 births (95% CI: -6.8, 1.0). In relative terms, this corresponds to a 5% increase in facility deliveries and a 9% reduction in NMR. There was no evidence of an increase in Caesarean deliveries. We examined lead and lag-time effects, finding evidence that facility deliveries continued to increase following fee removal. Our findings suggest removing user fees increased facility-based deliveries and possibly contributed to a reduction in NMR. Evidence from this evaluation may be useful to governments weighing the potential benefits of removing user fees.

Background The effort to increase access to emergency and surgical care in low-income countries has received global attention. While most of the literature on this issue focuses on workforce challenges, it is critical to recognize infrastructure gaps that hinder the ability of health systems to make emergency and surgical care a reality. Methods This study reviews key barriers to the provision of emergency and surgical care in sub-Saharan Africa using aggregate data from the Service Provision Assessments and Demographic and Health Surveys of five countries: Ghana, Kenya, Rwanda, Tanzania and Uganda. For hospitals and health centres, competency was assessed in six areas: basic infrastructure, equipment, medicine storage, infection control, education and quality control. Percentage of compliant facilities in each country was calculated for each of the six areas to facilitate comparison of hospitals and health centres across the five countries. Results The percentage of hospitals with dependable running water and electricity ranged from 22% to 46%. In countries analysed, only 19-50% of hospitals had the ability to provide 24-hour emergency care. For storage of medication, only 18% to 41% of facilities had unexpired drugs and current inventories. Availability of supplies to control infection and safely dispose of hazardous waste was generally poor (less than 50%) across all facilities. As few as 14% of hospitals (and as high as 76%) among those surveyed had training and supervision in place. Results Conclusions No surveyed hospital had enough infrastructure to follow minimum standards and practices that the World Health Organization has deemed essential for the provision of emergency and surgical care. The countries where these hospitals are located may be representative of other low-income countries in sub-Saharan Africa. Thus, the results suggest that increased attention to building up the infrastructure within struggling health systems is necessary for improvements in global access to medical care.

Abstract This article explores how malaria control in sub-Saharan Africa is shaped in important ways by political and economic considerations within the contexts of aid-recipient nations and the global health community. Malaria control is often assumed to be a technically driven exercise: the remit of public health experts and epidemiologists who utilize available data to select the most effective package of activities given available resources. Yet research conducted with national and international stakeholders shows how the realities of malaria control decision-making are often more nuanced. Hegemonic ideas and interests of global actors, as well as the national and global institutional arrangements through which malaria control is funded and implemented, can all influence how national actors respond to malaria. Results from qualitative interviews in seven malaria-endemic countries indicate that malaria decision-making is constrained or directed by multiple competing objectives, including a need to balance overarching global goals with local realities, as well as a need for National Malaria Control Programmes to manage and coordinate a range of non-state stakeholders who may divide up regions and tasks within countries. Finally, beyond the influence that political and economic concerns have over programmatic decisions and action, our analysis further finds that malaria control efforts have institutionalized systems, structures and processes that may have implications for local capacity development.

Single motherhood in sub-Saharan Africa has received surprisingly little attention, although it is widespread and has critical implications for children's well-being. Using survival analysis techniques, we estimate the probability of becoming a single mother over women's life course and investigate the relationship between single motherhood and child mortality in 11 countries in sub-Saharan Africa. Although a mere 5 % of women in Ethiopia have a premarital birth, one in three women in Liberia will become mothers before first marriage. Compared with children whose parents were married, children born to never-married single mothers were significantly more likely to die before age 5 in six countries (odds ratios range from 1.36 in Nigeria to 2.61 in Zimbabwe). In addition, up to 50 % of women will become single mothers as a consequence of divorce or widowhood. In nine countries, having a formerly married mother was associated with a significantly higher risk of dying (odds ratios range from 1.29 in Zambia to 1.75 in Kenya) relative to having married parents. Children of divorced women typically had the poorest outcomes. These results highlight the vulnerability of children with single mothers and suggest that policies aimed at supporting single mothers could help to further reduce child mortality in sub-Saharan Africa.

Background Specialized drug shops such as pharmacies and drug shops are increasingly becoming important sources of treatment. However, knowledge on their regulatory performance is scarce. We set out to systematically review literature on the characteristics, knowledge and practices of specialized drug shops in Sub-Saharan Africa. Methods We searched PubMed, EMBASE, WEB of Science, CAB Abstracts, PsycINFO and websites for organizations that support medicine policies and usage. We also conducted open searches using Google Scholar, and searched manually through references of retrieved articles. Our search included studies of all designs that described characteristics, knowledge and practices of specialized drug shops. Information was abstracted on authors, publication year, country and location, study design, sample size, outcomes investigated, and primary findings using a uniform checklist. Finally, we conducted a structured narrative synthesis of the main findings. Results We obtained 61 studies, mostly from Eastern Africa, majority of which were conducted between 2006 and 2011. Outcome measures were heterogeneous and included knowledge, characteristics, and dispensing and regulatory practices. Shop location and client demand were found to strongly influence dispensing practices. Whereas shops located in urban and affluent areas were more likely to provide correct treatments, those in rural areas provided credit facilities more readily. However, the latter also charged higher prices for medicines. A vast majority of shops simply sold whatever medicines clients requested, with little history taking and counseling. Most shops also stocked popular medicines at the expense of policy recommended treatments. Treatment policies were poorly communicated overall, which partly explained why staff had poor knowledge on key aspects of treatment such as medicine dosage and side effects. Overall, very little is known on the link between regulatory enforcement and practices of specialized drug shops. Conclusions Evidence suggests that characteristics and practices of specialized drug shops differ across rural and urban locations, and that these providers are highly responsive to client demand. However, there is a dearth in knowledge on how regulatory enforcement influences their characteristics and practices, and what strategies can be employed to strengthen the governance of the retail pharmaceutical sector.