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
Authors: Seward Nadine , Hanlon Charlotte , Abdulahi Ahmed , Abrams Zulfa , Alem Atalay , Araya Ricardo , Bachmann Max , Bogale Birke , Brima Nataliya , Chibanda Dixon , Curran Robyn , Davis Justine , Deneke Andualem , 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 , Sheenan Andrew , Tadesse Amezene , Thornicroft Graham , Rensburg André van , Sevdalis Nick , Verhey Ruth , Willot Chris , Prince Martin 
Published: January 2021

Abstract
ObjectivesTo 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 HeAlth System StrEngThening 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. SettingsPublicly 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 deliveryIn 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.ConclusionsASSET 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.