Health system strengthening in sub-Saharan Africa (ASSET) Work Package Research Protocols Health system strengthening in sub-Saharan Africa (ASSET) Work Package Research Protocols ETHIOPIA: WORK PACKAGES 1 – 3 ....................................................................... 2 SOUTH AFRICA: WORK PACKAGE 4 .................................................................... 52 SOUTH AFRICA: WORK PACKAGE 5 .................................................................... 72 SOUTH AFRICA: WORK PACKAGE 6 .................................................................... 86 SIERRA LEONE: WORK PACKAGE 7 ..................................................................... 96 ZIMBABWE: WORK PACKAGE 8 ........................................................................ 113 1 Health system strengthening in sub-Saharan Africa (ASSET) Work Package Research Protocols ETHIOPIA: WORK PACKAGES 1 – 3 Study Design: Implementation research, health systems research, mixed qualitative and quantitative methods Investigators Overall Principal investigator & Lead PI for (1) Integrated NCD/mental health, and (2) Violence against women Dr Charlotte Hanlon, CDT-Africa, College of Health Sciences, Addis Ababa University (AAU), Ethiopia; Email: [email protected] Lead co-PI (cross-project) Professor Martin Prince, Global Health Unit for Health System Strengthening, King’s College London, UK. Email: [email protected] Co-investigator (cross-project, policy) Dr Desalegn Tegabu, Director, Policy and Planning Directorate, Federal Ministry of Health of Ethiopia Email: [email protected] Co-investigator (cross-project: statistics) Dr Girmay Medhin, Aklilu-Lemma Institute of Pathobiology, Addis Ababa University Email: [email protected] Co-investigator (integrated primary care) Dr Abebaw Fekadu, Director, CDT-Africa, College of Health Sciences, Addis Ababa University (AAU), Ethiopia; Email: [email protected] Co-investigator (integrated primary care) Dr Helen Yifter, Department of Internal Medicine, School of Medicine, College of Health Sciences, AAU, Ethiopia; Email: [email protected] Co-PI (NCD/mental health) Professor Atalay Alem, Department of Psychiatry, School of Medicine, College of Health Sciences, AAU, Ethiopia; Email: [email protected] Co-investigator (NCD/mental health) Dr Tewodros Haile, Division of Pulmonary and Critical Care, Department of Internal Medicine, School of Medicine, College of Health Sciences, AAU, Ethiopia; Email: [email protected] Co-investigator (NCD/mental health) Dr Lara Fairall, Knowledge Translation Unit, University of Cape Town, South Africa Email: [email protected] Co-investigator (maternal healthcare) Dr Solomon Shiferaw, School of Public Health, College of Health Sciences, AAU, Ethiopia. Email: [email protected] 2 Health system strengthening in sub-Saharan Africa (ASSET) Work Package Research Protocols Lead PI (maternal healthcare) Dr Ahmed Abdella, Department of Obstetrics and Gynaecology, School of Medicine, College of Health Sciences, AAU, Ethiopia; Email: [email protected] Co-investigator (maternal healthcare) Professor Andy Shennan, Department of Women’s Health, King’s College London, UK. Email: [email protected] Co-investigator (maternal healthcare) Professor Jane Sandall, Department of Women’s Health, King’s College London, UK. Email: [email protected] Co-investigator (violence against women) Dr Negussie Deyessa, School of Public Health, College of Health Sciences, AAU, Ethiopia. Email: [email protected] Co-investigator (violence against women) Professor Louise Howard, Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London. Email: [email protected] Co-investigator (violence against women) Dr Roxanne Keynejad, Section of Women’s Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London. Email: [email protected] Co-investigator (maternal healthcare) Dr Tanya Robbins, Department of Women’s Health, King’s College London, UK. Email: [email protected] Lead PI (surgery) Dr Andualem Deneke, Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University; Email: [email protected] Co-PI (surgery) Dr Amezene Tadesse, Consultant General Pediatric Surgeon, Tikur Anbessa Hospital, Addis Ababa University Email: [email protected] Co-investigator (surgery) Dr Abebe Bekele, Department of Surgery, School of Medicine, College of Health Sciences, AAU, Ethiopia; Email: [email protected] Co-investigator (surgery) Dr Andy Leather, Director, King’s Centre for Global Health, King’s College London Email: [email protected] Co-investigator (surgery) Professor Justine Davies, King’s Centre for Global Health, King’s College London Email: [email protected] 3 Health system strengthening in sub-Saharan Africa (ASSET) Work Package Research Protocols Co-investigator (Surgery/dental) Dr Wondwossen Fantaye, Head, Department of Dentistry, School of Medicine, College of Health Sciences, Addis Ababa University, Email: [email protected] Co-investigator (Surgery) Professor Jennifer E Gallagher, King’s College London Dental Institute, King’s College London Email: [email protected] Executive summary Background Health system strengthening is needed in order to achieve quality, integrated continuing healthcare and improved patient outcomes. In Ethiopia, the Federal Ministry of Health is introducing evidence-based guidelines for common conditions encountered in primary care (the Ethiopia primary health care clinical guidelines). The guidelines have a particular focus on non-communicable diseases (NCDs), mental health and women’s health. TheMinistry of Health has also launched a programme (Saving Lives Through Safe Surgery; SaLTS) focused on improving access to quality surgical care. To fully realise the potential of these important initiatives, we need high quality evidence on effective interventions to strengthen the health system around these programmes. Overall aims The overall aim of ASSET (health system strengthening in sub-Saharan Africa) is to develop effective health system strengthening interventions to support the translation of clinical evidence into delivery of integrated continuing care at scale across healthcare platforms for NCDs, mental and substance use problems, surgical and dental care, and maternal healthcare in Ethiopia. Specific aims For NCDs/mental healthcare, maternal healthcare and surgical/dental care: (1) To identify the health system bottlenecks to delivery of integrated, quality continuing care (2) To adapt, pilot and refine health system strengthening interventions based on (A) defining care pathways, (B) electronic information systems, (C) quality improvement, (D) person-centred care), and (E) workforce strengthening. (3) To implement and evaluate the impact of these health system strengthening interventions upon patient outcomes. Methods The diagnostic phase of ASSET will include the following: (1) Theory of Change workshops with key stakeholders (2) Situation analysis based on data available in the public sector (3) Process mapping facility-based studies to understand pathways through care (4) Observational studies of person-centred care and fidelity to treatment guidelines (5) Surveys of patient knowledge and experience of person-centred care (6) Cross-sectional facility-based studies of health worker detection of focus conditions (7) Community survey of surgical conditions: burden, help-seeking and barriers to care 4 Health system strengthening in sub-Saharan Africa (ASSET) Work Package Research Protocols (8) Qualitative studies with key stakeholders During the piloting phase, health system strengthening interventions will be adapted, piloted and assessed using process data and qualitative studies. In the implementation phase, the impact of adapted health system strengthening interventions upon patient level outcomes will be evaluated. Expected results The diagnostic phase will identify health system bottlenecks to the implementation of integrated primary and maternal healthcareand increased access to quality surgical care. The output will be a comprehensive integrated district level plan. The overall ASSET study will provide rigorous and relevant evidence on effective and feasible health system strengthening interventions to support integrated primary care and quality surgical care. Funding Funded through a grant from the UK National Institute of Health Research (NIHR) Keywords Health system strengthening; implementation research; quality improvement research; mhealth; global surgery; mental health; substance use; violence against women; non-communicable diseases; maternal health Overall background ASSET-Ethiopia is a collaborative project between Addis Ababa University, King’s College London, University of Cape Town and the University of KwaZulu-Natal. The focus of ASSET-Ethiopia is on the development and evaluation of interventions to strengthen the Ethiopian health system to support quality, integrated, continuing care in the areas of integrated primary care for non-communicable diseases (NCDs), mental health problems and substance use disorders, maternal health, health consequences of violence against women (VAW) and surgical and dental health. Health system challenges and opportunities in Ethiopia The Ethiopian health system is in transition. In the Federal Ministry of Health (FMoH) 20-year vision for the health system (1), primary care is placed at the centre of efforts to