HeAlth System StrEngThening in four sub_Saharan African countries (ASSET) to achieve high-quality, evidence-informed surgical, maternal and newborn, and primary care: protocol for pre-implementation phase studies
Open accessAbstract
Objectives: To achieve universal health coverage, health systems need to be strengthened to support the consistent delivery of high-quality, evidence-informed care at scale. The aim of the National Institute for Health Research (NIHR) Global Research Unit on He A lth S ystem S tr E ng T hening in Sub-Saharan Africa (ASSET) is to address this need in a four-year programme spanning three healthcare platforms (primary health care for the integrated treatment of chronic conditions in adults, maternal and newborn, surgical care) involving eight work packages. This paper describes the pre-implementation phase research protocols that assess: (1) barriers to accessing care; (2) health system bottlenecks in care process and pathways; (3) quality of care, and; (4) people centredness. Findings from this research are used to engage stakeholders and to inform the selection of a set of health system strengthening interventions (HSSIs) and subsequent methodology for evaluation. Settings: Publicly funded health systems in rural and urban areas in Ethiopia, Sierra Leone, South Africa, and Zimbabwe. Population: Stakeholders including patients and their caregivers, community representatives, clinicians, managers, administrators, and policymakers. Study methodologies and delivery: In each work package, we apply a mixed-methods approach, including: literature reviews; situation analyses; cohort studies; cross-sectional surveys; ethnographic observations; semi-structured interviews, and; focus group discussions. At the end of the pre-implementation phase, findings are fed back to stakeholders in participatory theory of change workshops that are used to select/adapt an initial set of contextually relevant HSSIs. To ensure a theory-informed approach across ASSET, implementation science determinant frameworks are also applied, to help identify any additional contextual barriers and enablers and complementary HSSIs. Outputs from these activities are used to finalise underlying assumptions, potential unintended consequences, process indicators and implementation and clinical outcomes. Conclusions: ASSET places a strong emphasis of the pre-implementation phase of the programme in order to provide an in-depth and systematic diagnosis of the existing heath system functioning, needs for strengthening and active stakeholder engagement. This approach will inform the design and evaluation of the HSSIs to increase effectiveness across work packages and contexts, to better understand what works, for whom, and how. Strengths and limitations of this study: The National Health Institute of Research (NIHR) Global Research Unit on Health System Strengthening in sub-Saharan Africa (ASSET) is a four-year programme (2017-2021) that is closely aligned with the SDG goal of UHC, and the recommendations of the Lancet Commission for High Quality Health Systems. The aim of ASSET is to develop and evaluate effective and sustainable HSSIs, promoting consistent delivery of high-quality, people-centred care. The ASSET programme is being conducted in two phases including the diagnostic pre-implementation and piloting/rolling implementation phase. The purpose of this paper is to describe the methodology for the pre-implementation phase, which has the core aim of mapping comprehensive care pathways of a patient’s journey though the health system including the community, different providers), and health facilities, documenting what care is provided at what level of the health system and the associated health system bottlenecks. At the end of the pre-implementation phase of ASSET, it is hoped the common approach taken across different countries, care platforms and health conditions will facilitate cross platform learning and understanding of how differences in health systems and broader contextual influences shaped the development of the interventions. The overarching expectation is that by using an in-depth participatory process to engage with the stakeholders and map care pathways to and through the health system, we develop a HSS programme that can be implemented at scale that meets the needs and priorities of the local community.
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In most low-income and many middle-income countries, the provision of surgery and anaesthesia care is inadequate in quantity and quality.
“In most low-income, and many middle-income countries, the provision of surgery and anaesthesia care is inadequate in quantity and quality.1”
From Towards equitable surgical systems: development and outcomes of a national surgical, obstetric and anaesthesia plan in Tanzania (2019) · cites this paper as [1]
There is an unmet need for 143 million additional surgical procedures each year worldwide.
“and there is an unmet need for 143 million additional surgical procedures each year.1”
From Towards equitable surgical systems: development and outcomes of a national surgical, obstetric and anaesthesia plan in Tanzania (2019) · cites this paper as [1]
The surgical system of a country like Tanzania can be assessed using six core indicators proposed by the LCoGS.
“The surgical system of a country like Tanzania can be assessed using six core indicators proposed by the LCoGS.”
From Towards equitable surgical systems: development and outcomes of a national surgical, obstetric and anaesthesia plan in Tanzania (2019) · cites this paper as [1]
A large proportion of the world's population lacks access to safe, timely and affordable surgical and anaesthesia care (5 billion people; 65% of the world population).
“Despite emergency and essential surgery and anaesthesia care being recognised as a part of Universal Health Coverage, 5 billion people worldwide lack access to safe, timely and affordable surgery and anaesthesia care.”
From Towards equitable surgical systems: development and outcomes of a national surgical, obstetric and anaesthesia plan in Tanzania (2019) · cites this paper as [1]
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- [15]Seward N, Hanlon C, Abdulahi A, et al. HeAlth System StrEngThening in four sub_Saharan African countries (ASSET) to achieve high-quality, evidence-informed surgical, maternal and newborn, and primary care: protocol for pre-implementation phase studies. medRxiv. 2021 Jan 06; 20248468. DOI: 10.1101/2021.01.06.20248468. PMC8765245 35037844
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- Authors
- Seward, N., Hanlon, C., Abdulahi, A., Abrams, Z., Alem, A., Araya, R., Bachmann, M., Bogale, B., Brima, N., Chibanda, D., Curran, R., Davis, J., Deneke, A., Fairall, L., Frissa, S., Gallagher, J., Gao, W., Harding, R., Kartha, M. R., Leather, A., Lund, C., Marx, M., Nkhoma, K., Murdoch, J., Petersen, I., Petrus, R., Sandall, J., Sheenan, A., Tadesse, A., Thornicroft, G., van Rensburg, A., Sevdalis, N., Verhey, R., Willot, C., & Prince, M.
- Affiliations
- King's College London (GB)
- Addis Ababa University (ET)
- University of East Anglia (GB)
- University of Zimbabwe (ZW)
- University of Cape Town (ZA)
- University of KwaZulu-Natal (ZA)
- Corresponding author
- Seward, Nadine
- ORCID
- Seward, Nadine
- Hanlon, Charlotte
- Abrams, Zulfa
- Alem, Atalay
- Araya, Ricardo
- Bachmann, Max
- Bogale, Birke
- Brima, Nataliya
- Chibanda, Dixon
- Curran, Robyn
- Davis, Justine
- Fairall, Lara
- Frissa, Souci
- Gallagher, Jennifer
- Gao, Wei
- Harding, Richard
- Kartha, Muralikrishnan R.
- Leather, Andrew
- Lund, Crick
- Marx, Maggie
- Nkhoma, Kennedy
- Murdoch, Jamie
- Petersen, Inge
- Petrus, Ruwayda
- Sandall, Jane
- Tadesse, Amezene
- Thornicroft, Graham
- Sevdalis, Nick
- Verhey, Ruth
- Prince, Martin
- Venue
- Global Health Action
- Publisher
- openRxiv
- Published
- 2021-01-09
- Volume
- 15
- Issue
- 1
- Pages
- 1987044-1987044
- ISSN
- 1654-9716 (ISSN-L)
- PMC
- PMC8765245
- OpenAlex
- W4225679594
- Cited by
- 84
- References
- 49
- Citations by year
- 2026: 19 · 2025: 21 · 2024: 23 · 2023: 8 · 2022: 5 · 2021: 6 · 2020: 1 · 2019: 1
- FWCI
- 16.36
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- Global Health Action (publishedVersion, cc-by)
- medRxiv (acceptedVersion)
- Research Square (acceptedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Research Portal (King's College London) (publishedVersion, cc-by)
- UEA Digital Repository (University of East Anglia) (acceptedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Minerva Access (University of Melbourne) (submittedVersion, cc-by)
- University of Birmingham Research Portal (University of Birmingham) (submittedVersion, cc-by)
- University of Birmingham Research Portal (University of Birmingham) (submittedVersion, other-oa)
- Edinburgh Research Explorer (University of Edinburgh) (submittedVersion, cc-by)
- SUNScholar (Stellenbosch University) (submittedVersion)
- Funders
- Government of the United Kingdom
- National Institute for Health and Care Research (16/136/54, GHRU 16/136/54)
- Department of Health and Social Care (16/136/54)
- King's College London (GHRU 16/136/54)
- National Institutes of Health (R023697, S001255, MR/S001255/1)
- Medical Research Council (MR/S001255/1, MR/R023697/1)
- National Institute of Mental Health (R01MH100470)
- Topics
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Health Professions › General Health Professions › Healthcare Systems and Practices
- Social Sciences › Economics, Econometrics and Finance › Finance › Healthcare Systems and Reforms
- Keywords
- health system strengthening, participatory research, stakeholder engagement, co-production, theory of change, situation analysis, universal health coverage, surgical care, maternal and newborn care, primary care, sub-Saharan Africa
- MeSH terms
- Cross-Sectional Studies, Delivery of Health Care, Government Programs, Humans, Infant, Newborn, Medical Assistance, Primary Health Care
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