Bruno Marchal

• MD, MPH, PhD
• Professor at Institute of Tropical Medicine

### Summary box Ridde recently called for a commitment to implementation science and for ‘better quality research in order to have a greater understanding of how to implement health interventions’.1 He argued for better use of theory and implementation science studies that contribute to theory. This is indeed of paramount importance, especially fo...

The 400 million indigenous people worldwide represent a wealth of linguistic and cultural diversity, as well as traditional knowledge and sustainable practices that are invaluable resources for human development. However, indigenous people remain on the margins of society in high, middle and low-income countries, and they bear a disproportionate bu...

In this paper, we respond to a paper by Jamal and colleagues published in Trials in October 2015, taking the opportunity to continue the much-needed debate about what applied scientific realism is. The paper by Jamal et al. is useful because it exposes the challenges of combining a realist evaluation approach (as developed by Pawson and Tilley) wit...

Objectives: This paper presents the results of a realist evaluation that aimed to understand how, why and under what circumstances a Red Cross (RC) capacitybuilding intervention influences the motivation and the performance of RC community health volunteers involved in the delivery of an immunisation programme in Kampala, Uganda. Method: Given the...

The initial program theory (IPT) is a core element of realist evaluation. An IPT presents a hypothesis about how, for whom, why, and in what contexts an intervention is effective. Despite their importance within realist studies, methodological guidance on how to develop an IPT is relatively scarce. We describe the methodological process of elicitin...

Since 2014, the health sector in the Democratic Republic of the Congo has been undergoing reforms aimed at strengthening the Provincial Health Administration (PHA) to better support health district development through technical support to district health management teams (DHMTs). However, there is limited understanding of how, for whom, and under w...

The need for leadership in and of district health systems is critical for the effective delivery of services and for inter-sectoral collaboration for health. Leadership capacity development has not, however, been prioritised within health systems and the systemic capacity (i.e. roles, structures, and processes) that is needed to develop managers wh...

Background Worldwide, 10% of postpartum women experience postpartum depression, which can lead to diverse sequalae at individual, family, and societal levels. In sub-Saharan Africa, it is estimated that 17% of women experience depression in the postpartum period, which could be an underestimate as 48% of women in the region do not receive postnatal...

Background The COVID-19 pandemic has demanded crisis management at all governance levels. While most research has focused on responses of national governments, city-level governance had significant potential to develop tailored approaches. This study explored how the local COVID-19 response was organised and adapted to the specific city population...

Background: It is commonly argued that resilient health systems ensure the well-being of populations even under critical conditions, whereas poorly resilient ones may be disrupted and collapse. We aimed to examine how health system resilience can be assessed as this issue is still under debate. Methods: We conducted a scoping review of peer-reviewe...

Background In 2006, the Ministry of Health in the Democratic Republic of Congo designed a strategy to strengthen the health system by developing health districts. This strategy included a reform of the provincial health administration to provide effective technical support to district health management teams in terms of leadership and management. T...

Background An important consequence of climate change for urban health is heat-related mortality. Vulnerable groups, especially elderly, will be the most affected. A solution put forward in many reports and policy documents is the introduction or expansion of urban green spaces. While they have a proven effect in decreasing the ambient temperature...

Introduction A country’s ability to manage a crisis depends on its level of resilience. Efforts are made to clarify the concept of health system resilience, but its operationalisation remains little studied. In the present research, we described the capacity of the local healthcare system in the Islamic Republic of Mauritania, in West Africa, to co...

Background: In 2006, the Ministry of Health in the Democratic Republic of Congo designed a strategy to strengthen the health system by developing health districts. This strategy included a reform of the provincial health administration to provide effective technical support to District Health Management Teams in terms of leadership and management....

Introduction In humanitarian settings, aid agencies are constantly challenged by difficult decisions such as when and how to terminate aid without harming the aid recipients, local institutions, staff members and the organisation. Despite important efforts devoted to responsibly leaving a setting, hurtful exits are still common in contemporary reli...

Objectives We aimed to understand how capacity building programmes (CBPs) of district health managers (DHMs) have been designed, delivered and evaluated in sub-Saharan Africa. We focused on identifying the underlying assumptions behind leadership and management CBPs at the district level. Design Scoping review. Data sources We searched five elect...

Introduction In 2006, the Congolese Ministry of Health developed a health system strengthening strategy focusing on health district development. This strategy called for reforming the provincial health administration in order to better support the health district development through leadership and management capacity building of district health man...

Realist evaluation is in essence a theory-building and testing approach. We argue that in practice, the theory-building potential of realist evaluation, review and research is not fully exploited in the field of global health. Our assumption is that the Structure-Agency-Culture explanatory framework of critical realist Margaret Archer could stimula...

Results of the Realist Evaluation component of the five-year research investigating the impact, mechanisms of effect and costs of the provider incentive payment scheme for Tuberculosis care in Georgia. The research is a collaboration of Curatio International Foundation (Georgia), Queen Margaret University (UK), London School of Hygiene and Tropical...

Health Facility Assessments (HFAs) assessing facilities’ readiness to provide services are well-established. However, HFA questionnaires are typically quantitative and lack depth to understand systems in which health facilities operate—crucial to designing context-oriented interventions. We report lessons from a multiple embedded case study explori...

Realist evaluation (RE) is a theory-driven evaluation approach inspired by scientific realism. It has become increasingly popular in the field of global health where it is often applied in low- and middle-income countries. This makes it timely to discuss RE's relationship to the emerging decolonisation of global health movement. In this short persp...

Introduction Despite a strong evidence base for developing interventions to reduce child mortality and morbidity related to pregnancy and delivery, major knowledge–implementation gaps remain. The Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) in sub-Saharan Africa project aims to overcome these gaps through strengthe...

Background Insufficient reductions in maternal and neonatal deaths and stillbirths in the past decade are a deterrence to achieving the Sustainable Development Goal 3. The majority of deaths occur during the intrapartum and immediate postnatal period. Overcoming the knowledge-do-gap to ensure implementation of known evidence-based interventions dur...

Full report available from: https://www.enabel.be/publication/chronic-respiratory-diseases-crd-africa

Background: Conditional cash transfers (CCTs) are interventions which provide assistance in the form of cash to specific vulnerable groups on the condition that they meet pre-defined requirements. The impact of conditional cash transfers on children's access to health services and on their overall health has not been established in sub-Saharan Afri...

Introduction: The objective of this study was to identify the factors that influenced the poor performance of the Community Observatory on Access to Health Services (OCASS) project during its implementation from 2014 to 2017 in Guinea and to formulate recommendations for the rest of the project. Methods: This was a qualitative study using the mu...

Realist evaluation is making inroads in the field of health policy and systems research to a large extent because of its good fit with complex issues. Until now, most realist studies focused on evaluating interventions or projects related to health care delivery, organization of health services, education, management, and leadership of health worke...

Objectives This paper presents the iterative process of participatory multistakeholder engagement that informed the development of a new national tuberculosis (TB) policy in Georgia, and the lessons learnt. Methods Guided by realist evaluation methods, a multistakeholder dialogue was organised to elicit stakeholders’ assumptions on challenges and p...

Executive Summary of the Strategy Paper

Executive summary in French of the Strategy Paper

Background As part of health system strengthening in South Africa (2012–2017) a new district health manager, taking a bottom-up approach, developed a suite of innovations to improve the processes of monthly district management team meetings, and the practices of managers and NGO partners attending them. Understanding capacity as a property of the h...

Background: . Implementation of healthcare regulatory policies, especially in low- and middle-income countries where the private health sector is predominant, is challenging. Karnataka, a southern state in India, enacted the Karnataka Private Medical Establishments Act (KPMEA) with an aim to ensure quality of care in the private healthcare establi...

Background Realist studies represent an increasingly popular approach for exploring complex interventions’ successes and failures. The theory-driven approach seeks to explain “what works, how, why, in which contexts, for whom, and to what extent” using context–mechanism–outcome (CMO) configurations. When the approach was first developed, CMO config...

Background As part of health system strengthening in South Africa (2012- 2017) a new district health manager, taking a bottom-up approach to developing managerial capacity, developed a suite of innovations to improve the processes and practices of managers and NGO partners in monthly district management team meetings. Using a systems perspective on...

Background As part of health system strengthening in South Africa (2012- 2017) a new district health manager, taking a bottom-up approach to developing management capacity, developed a suite of innovations to improve the processes and practices of managers and NGO partners in monthly district management team meetings. Understanding capacity as a pr...

Background: Access to qualitative and equitable healthcare is a major challenge in Mauritania. In order to support the country's efforts, a health sector strengthening programme was set up with participatory action research at its core. Reinforcing a health system requires a customised and comprehensive approach to face the complexity inherent to...

Objectives: This study aimed at opening the black box of the relationship between leadership and motivation of health workers by focusing on a high-performance hospital in Morocco. Design: We adopted the realist evaluation approach and used the case study design to test the initial programme theory we formulated on the basis of a scoping review...

Objectives: We aimed at exploring the underlying mechanisms and contextual conditions by which leadership may influence 'public service motivation' of health providers in Moroccan hospitals. Design: We used the realist evaluation (RE) approach in the following steps: eliciting the initial programme theory, designing the study, carrying out the d...

Background: In India, heterogenous tribal populations are grouped together under a common category, Scheduled Tribe, for affirmative action. Many tribal communities are closely associated with forests and difficult-to-reach areas and have worse-off health and nutrition indicators. However, poor population health outcomes cannot be explained by geog...

Background: Health systems in sub-Saharan Africa face multifaceted capacity challenges to fulfil their mandates of service provision and governance of their resources. Four academic institutions in Africa implemented a World Health Organisation-funded collaborative project encompassing training, curriculum development, and partnership to strengthe...

To improve access to maternal health services, Benin introduced in 2009 a user fee exemption policy for caesarean sections. Similar to other low- and middle-income countries, its implementation showed mixed results. Our study aimed at understanding why and in which circumstances the implementation of this policy in hospitals succeeded or failed. We...

Realist evaluation submits that theories and models of how, why, for whom and under what circumstances programs work could be formulated by conceptualizing the relational links between the context within which programs are implemented, the generative mechanisms the programs trigger, and the outcomes of interest. Qualitative and quantitative data co...

Background: The motivation of health workers is a key concern of policy makers, practitioners and researchers. Public Service Motivation (PSM), defined as the altruistic desire to serve the common interest, to serve others and to help patients and their families regardless of financial or external rewards, has been shown to be key to the performan...

Background Health systems in sub-Saharan Africa face multifaceted capacity challenges to fulfil their mandates of service provision and governance of their resources. Four academic institutions in Africa implemented a World Health Organisation-funded collaborative project encompassing training, curriculum development, and partnership to strengthen...

Corrigendum: Change co-author name to Stephen Maluka. Article abstract czz042: Priority setting within health systems has not led to accountable, fair and sustainable solutions to improving population health. Providers, users and other stakeholders each have their own health and service priorities based on selected evidence, own values, expertise...

Background Improving access to paediatric HIV treatment requires large-scale antiretroviral treatment programmes and medication adapted to infants and children’s needs. The World Health Organisation recommends lopinavir/ritonavir plus two nucleoside reverse transcriptase inhibitors as first-line treatment for all HIV-infected children younger than...

Priority setting within health systems has not led to accountable, fair and sustainable solutions to improving population health. Providers, users and other stakeholders each have their own health and service priorities based on selected evidence, own values, expertise and preferences. Based on a historical account, this article analyses if contemp...

Background: An estimated 7.9 million people were living with HIV in South Africa in 2017, with 63.3% of them remaining in antiretroviral therapy (ART) care and 62.9% accessing ART. Poor retention in care and suboptimal adherence to ART undermine the successful efforts of initiating people living with HIV on ART. To address these challenges, the ant...

L’évaluation réaliste (ER) explicite les mécanismes causaux des résultats d’une intervention dans différents contextes. En s’appuyant sur l’évaluation de la mise en œuvre d’une politique de santé en Afrique de l’Ouest, ce chapitre illustre les différentes étapes du cycle de l’ER. À la première étape, les questions de recherche sont formulées. La va...

Lehoux and colleagues plea for a health systems perspective to evaluate innovations. Since many innovations and their scale-up strategies emerge from processes that are not (centrally) steered, we plea for any assessment with a dynamic, instead of a sequential, approach. We provide further guidance on how to adopt such dynamic approach, in order to...

Introduction In 2016, Georgian researchers and policymakers were developing a policy to improve the performance of the national tuberculosis (TB) control programme. The research programme ‘Designing and Evaluating Provider Results-Based Financing for Tuberculosis Care in Georgia: Understanding Costs, Mechanisms of Effect and Impact (Results4TB)’ wa...

Background In 2012 the South African National Department of Health (SA NDoH) set out, using a top down process, to implement several innovations in eleven health districts in order to test reforms to strengthen the district health system. The process of disseminating innovations began in 2012 and senior health managers in districts were expected to...

Background Although empirical evidence suggests that the adherence club model is more effective in retaining people living with HIV in antiretroviral treatment care and sustaining medication adherence compared to standard clinic care, it is poorly understood exactly how and why this works. In this paper, we examined and made explicit how, why and f...

Observation guide. (DOCX)

Interview guide–health care providers. (DOCX)

Interview guide–patients. (DOCX)

Une couverture universelle des soins de santé en 2030 pour tous les êtres humains, du Nord au Sud ? Réaliser cet objectif de développement durable aussi ambitieux que nécessaire exigera une exceptionnelle volonté politique, mais aussi de solides données probantes sur les moyens d’y arriver, notamment sur les interventions de santé mondiale les plus...

Background: Digital innovations have shown promise for improving maternal health service delivery. However, low- and middle-income countries are still at the adoption-utilization stage. Evidence on mobile health has been described as a black box, with gaps in theoretical explanations that account for the ecosystem of health care and their effect on...

Background The integration of mental health services into primary care is essential to improve the coverage of mental health services in low resource settings, but the evaluation of this remains challenging. We used a programme’s Theory of Change (ToC) as a conceptual framework to determine what combination(s) of conditions at facility and communit...

Background Youth-friendly health care services can facilitate young people’s access to health care services and promote their health, including their mental health. In Sweden, a network of youth health centers exist since the 1970s, incorporated within the public health system. Even if such centers take a holistic approach to youth health, the focu...

S1_-_Observation_guide – Supplemental material for “Patients Are Not Following the [Adherence] Club Rules Anymore”: A Realist Case Study of the Antiretroviral Treatment Adherence Club, South Africa

S2_-_Interview_guide-clinicians – Supplemental material for “Patients Are Not Following the [Adherence] Club Rules Anymore”: A Realist Case Study of the Antiretroviral Treatment Adherence Club, South Africa

S3_-_Interview_guide-patients – Supplemental material for “Patients Are Not Following the [Adherence] Club Rules Anymore”: A Realist Case Study of the Antiretroviral Treatment Adherence Club, South Africa

Introduction: Nowadays, health systems are generally acknowledged to be complex social systems. Consequently, scholars, academics, practitioners, and policy-makers are exploring how to adopt a complexity perspective in health policy and system research. While leadership and complexity has been studied extensively outside health, the implications of...

Supplemental material 1 for Mobile health and the performance of maternal health care workers in low- and middle-income countries: A realist review

Supplemental material 2 for Mobile health and the performance of maternal health care workers in low- and middle-income countries: A realist review

Supplementary file 1. List of Included Studies.

Supplementary file 2. Complex Leadership Studies in Non-healthcare Settings and Reasons for Exclusion.

Supplementary file 3. Measurement and Interpretation of Kappa Coefficient

Supplementary file 4. Research Question in Complex Leadership

Supplementary file 5. Scope, Epistemology, Theory and Conceptual Definitions of Complex Leadership.

Supplementary file 6. Categorization Criteria of Included Papers.

Background: A free obstetric care policy (FOCP) has been implemented in Morocco in 2008 in order to further decrease maternal mortality. Methods: Through in-depth interviews we explored the perceptions of health professionals in public Moroccan hospitals with regard to fee exemption policies. We tried to understand what drives health professionals...