Title: NIHR Global Health Research Unit on Health System Strengthening in Sub-Saharan Africa, King's College London
Funder: Department of Health and Social Care

Abstract: KCL Global Health Strategy As a global top 20 University, with strengths in biomedical education and research, KCL recognised a need to cohere its global health (GH) activities, with a solid base and plan for investment and growth. The new King’s GH Institute (KGHI) is a focal point for King’s GH researchers, a mark of our institutional commitment, and a catalyst for a step change in the scale and impact of our research and education. KGHI’s vision is to establish a cutting-edge interdisciplinary research program, strengthening health systems and services to be ‘fit for purpose’ to deliver universal coverage of quality continuing care in resource-poor settings. This relates to KCL’s GH strengths in areas also directly relevant to new UN SDG priorities; health system strengthening/ workforce development; NCDs (mental health, ageing, surgery, cancer care, palliative care, dental health); maternal/newborn health; and environment and health. Recent investment in global affairs (Country Institutes, International Development Institute), policy studies (Policy Institute at King’s) and social science (Dept. of GH & Social Medicine) foster interdisciplinary research and education. Our iBSc in GH, and MScs in GH, Global Mental Health, and GH and Social Justice attract 160 students annually. KCL plays a leading role in the South London CLAHRC (King’s Centre for Implementation Science coordinates implementation and QI research across health themes), and in two NIHR BRCs (GSTT/ KCL and Maudsley; clinical informatics and translational medicine). The KCL NIHR Unit, careSSA, will be a KGHI flagship project, and a first step to achieving our vision. It will support our partnership strategy “to focus on high value partnerships, where there is good research infrastructure and established collaborations with KCL that can be broadened and deepened; but also committing to long-term research capacity building with less developed partners with important need and potential”. careSSA draws on expertise from KCL-wide centres (Global Mental Health, GH and Health Partnerships, Implementation Science, Women’s Health, King’s Health Economics) the Cicely Saunders Institute for Palliative Care, and Dept. of GH & Social Medicine. 14 Professors, 3 Readers, and 8 Senior lecturers, including 2 NIHR professors and 3 NIHR senior investigators will contribute directly to careSSA. The NIHR Unit will fund early career researcher posts dedicated to GH in Implementation Science, Health Economics, Social Science, Palliative Care and Women’s Health, which we aim to sustain beyond the funding period. KCL has invested in KHGI infrastructure; a Director (0.4FTE), two Deputies (2 x 0.2FTE) and FT support for administration, comms and events, and will commit to fund a Chair of Global Healthcare Delivery Science and a 0.5FTE GH lecturer to support the NIHR Unit, with 3 PhD fellowships for its doctoral training program. SCIENTIFIC STRATEGY NOTE: MORE DETAIL ON CARE PLATFORM INTERVENTIONS AND INTERDISCIPLINARY RESEARCH IS PROVIDED IN ‘ADDITIONAL INFORMATION’, INDICATED IN THE TEXT BY # The care that we seek to improve is delivered in 8 settings (determined by local priorities elicited, so far, by consultation with MoH, researchers and providers in each country - see ODA statement and support letters): South Africa (SA): 1. Integrated PHC for depression comorbid with TB, 2. PHC palliative care for chronic progressive conditions, and 3. Maternal care - detection and management of antenatal depression (AND) and violence against women (VAW) Ethiopia (ETH): 1. Integrated PHC for depression comorbid with NCDs, 2. Maternal care - detection and management of AND and VAW, and risk stratification (early detection and management of pre-eclampsia, sepsis, haemorrhage)#, 3. surgical care# Zimbabwe (ZIM): PHC detection and management of depression Sierra Leone (SL): surgical care# Our starting point is that care is, or will be, guideline-based care (GBC). In SA PACK (Practical Approach to Care Kit (1))# has been rolled out to all PHC and maternal care facilities where we work. MoH in ETH has committed to scale-up PACK as its adult PHC and maternal care standard, and we will pilot this in 3 districts. The Friendship Bench care system for detection/management of depression (2) is being scaled-up across Harare's PHCs. Surgical care in SL and ETH is supported by WHO guidelines and recommendations. In each setting our research will: a) identify and evaluate system approaches to enhance guideline operationalisation; more explicit care pathways, manualised interventions, and technologies to improve detection/ diagnosis (guideline optimisation) # b) identify health system-strengthening needs for more effective delivery of GBC (health system assessment/ diagnostic phase) c) develop and refine content and delivery of tailored health-system strengthening interventions (HSSI), with rigorous piloting and evaluation (development and piloting phase) d) evaluate the effects of scaling-up the resulting HSSI package, on GBC processes and outcomes HSSI are underused in LMIC, particularly SSA, and rarely documented and evaluated with rigour. Our common approach, adapted to the 8 care settings will ensure strong interactivity between the Unit’s research elements. Interactivity is further enhanced through 3 interdisciplinary research themes across countries/platforms; social science, exploring mechanisms/ instruments to promote equity in healthcare and health outcomes (Dept. of GH & Social Medicine #); policy research (Policy Institute at King’s – see Pathways to Impact); and economic evaluation (King’s Health Economics) supporting HSSI evaluation by developing a) tools to quantify local unit costs directly (avoiding need to estimate from HIC unit costs adjusted by GDP), and b) preference-based HRQOL outcome measures for QALY cost-utility analysis#. Core domains of HSSI and QI for continuing care are well established, from research, and consensus (3-9). We scoped relevant literature, and are guided by our experience implementing task-shifted GBC for mental disorders (10), nurse-led PHC GBC in SA (1), and contributions to 6 Lancet Series (11-20). Substantial evidence supports effectiveness of domains of the Chronic Care Model (Delivery System Design, Self-Management Support, Decision Support, Clinical Information Systems and Healthcare organization) (21-23). For resource-poor settings in SSA, we operationalise these into 5 HSSI elements: 1. evidence-based care pathways, with practice-based training, ongoing mentoring and support for implementation 2. HMIS data to monitor and improve CC quality and outcomes – detection, engagement on care pathways, adherence, retention and ‘treatment to target’ (mHealth app) 3. a peer-driven QI culture, with motivated healthcare workers (HCW) taking responsibility for improving care processes and outcomes (a ‘learning health systems approach’) 4. person-centred care reflecting patient values and preferences, agreed care plans and empowerment for self-management 5. workforce strengthening to prepare for organisational change, and foster non-technical skills (e.g. leadership, teamwork, communication, counselling, and stress management RESEARCH PLAN Y1-2 Short term – formative research we shall 1. Describe and evaluate the ‘localisation’ of PACK GBC for integrated PHC and maternal care to the ETH system – including practice-based training and mentoring procedures, and their impact on HCW competencies 2. Conduct focused systematic reviews to clarify existing evidence on HSSI relevant to SSA 3. Carry out pre-intervention assessment of care systems, end-to-end, from operational, HCW and patient experience perspectives. Quantitative, qualitative, direct observation and patient record data, from sampled facilities, on HCW numbers, roles, skills and organisation, equipment, patient flows, care processes and outcomes, and staff and patient perceptions on services offered. These data, and HMIS returns, will be used to diagnose specific HSS needs in each setting, and to develop unit cost estimation models 4. initiate development/field-testing of a basic prototype Mhealth app to record detection, engagement, adherence and treatment to target, for one condition, in one site, with data transfer protocols and analytics infrastructure# 5. conduct a household survey in ETH with the same design used recently in SL (24) to determine baseline unmet surgical need, access barriers, and deaths attributable to surgical conditions, and b) to elicit values attached to health states described by the WHODAS 2.0 HRQOL outcome scale, using valuation methods adapted to the context # Y2-3 Medium-term – intervention development and piloting 1. Address specific HSS needs for each platform by co-developing, or adapting relevant HSSI, with managers, HCW and patients, 2. Pilot and fine-tune these HSSI in iterative Phase II trials assessing feasibility, acceptability, fidelity, implementation facilitators/ barriers, and outcomes. Implementation plans will be guided by ‘Theory of Change’ (ToC) workshops, a participatory methodology, involving all relevant stakeholders. Y3-4 Long-term – intervention evaluation 1. Plan scale up of the integrated suite of HSSI to district level, and process evaluation, using ToC workshops 2. In the scale up all facilities will have been trained to deliver GBC. Half of the facilities will be selected to be trained in system enhancements to GBC, with HSSI. We considered all options before provisionally opting for a quasi-experimental ‘controlled before and after’ (CBA) design, with a detailed case study of the intervention arm. Controlled interrupted time series (ITS) evaluations may not be feasible given poor quality routine data for most relevant outcomes. ITS without control may be appropriate for surgical care platforms, given the small number of facilities, all of which will receive the HSSI

Lay abstract: Healthcare across sub-Saharan Africa (SSA) reaches too few of those in need (treatment gap), and does not achieve the best possible results (outcome gap). Resources are limited, so non-specialists provide most treatments. In South Africa nurses lead 90% of primary healthcare (PHC) consults, in Sierra Leone non-specialists perform 52% of surgical procedures, and Zimbabwe and Ethiopia have fewer than 1 psychiatrist per million. In this context, improving healthcare is challenging, but essential to progress. Our Global Health Research Unit on Health System Strengthening in Sub-Saharan Africa (ASSET) aims to improve delivery and outcomes of continuing care. Continuing care models apply to common chronic disease and illness episode management in PHC. Hypertension, diabetes, lung disease, HIV, TB and depression contribute a substantial and increasing burden in SSA PHC, and often co-occur. Continuing care is also relevant to maternal care (antenatal care, delivery, postnatal care) and surgical care (help-seeking, referral, admission, surgery and post-operative care). High quality continuing care is structured into evidence-based care pathways; integrated and coordinated; and holistic, person-centred and respectful. Health system strengthening interventions (HSSI) with continuous quality improvement are needed to mould services in SSA to be fit for this purpose. Attempts to introduce guidelines or new services without addressing system level barriers usually fail. We are working across 4 SSA countries (Ethiopia, South Africa, Sierra Leone, Zimbabwe) and 3 healthcare platforms (integrated PHC for mental and physical conditions, maternal, and surgical care), reflecting our research strengths and partnerships, and priorities for Ministry of Health, and research and service provider partners in these countries. We are testing the practicability and effectiveness of HSSI to build capacity across platforms to deliver high quality guideline-based continuing care. These HSSI are evidence-based, but, in SSA, mainly from demonstration projects of single elements: 1. evidence-based care pathways for integrated PHC for mental and physical conditions, maternal care, and high volume surgical procedures, with training, mentoring and support to implement them 2. essential data, used to monitor and improve the quality of continuing care and its outcomes 3. a peer-driven quality improvement culture, with motivated, well-trained and supported healthcare staff incentivized to take responsibility for improving care and its outcomes (a ‘learning health systems approach’) 4. person-centred care, guided by individual values and preferences, with agreed care plans and patients more empowered for self-management 5. workforce strengthening to prepare for necessary organisational changes, and foster non-technical skills (leadership, teamwork, communication, counselling, and stress management) In our research plan, HSSI will be adapted to local contexts, piloted and refined, and then applied as a package of measures to improve care delivery. The key test will then be whether, when scaled up and evaluated at district-level, there is significant improvement in the quality of care processes, AND health outcomes. Key indicators include; for PHC – detection, treatment and control of priority conditions; for maternal care – maternal deaths and near misses, birth complications, perinatal deaths; and for surgical care – surgical volume, deaths and complication rate

Research activity codes: 7.4 RESOURCES AND INFRASTRUCTURE (DISEASE MANAGEMENT);8.5 RESOURCES AND INFRASTRUCTURE (HEALTH SERVICES)
Health categories: GENERIC HEALTH RELEVANCE;MENTAL HEALTH;REPRODUCTIVE HEALTH AND CHILDBIRTH