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What 15 Years of Research in Africa Reveals About Resilient and Responsive Health Systems

Partnerships and large-scale models of care that link research and workforce training directly to the delivery of integrated primary health care are essential to saving lives. Without a strong, resilient and responsive health system in place, disease-focused programs and other narrowly targeted health interventions are left with nothing to carry them and cannot succeed. This is the premise of the Doris Duke Charitable Foundation’s African Health Initiative (AHI), which launched in 2007 with the goal to strengthen health systems in sub-Saharan Africa.   

In 2015, we shared a series of articles that documented program design, challenges to implementation, and preliminary outcomes from the initiative’s first phase. Now, more than 15 years since the initiative began, we are pleased to present the research findings from the second and final phase of this journey, featured in a supplement to the September 2022 issue of Global Health: Science and Practice.

In the African Health Initiative’s first phase, the foundation awarded four grants to pilot a variety of health systems strengthening interventions in Ghana, Mozambique, Rwanda, Tanzania and Zambia. Though not all activities had the desired impact, several resulted in measurable improvements to health system performance. The encouraging results prompted a follow-up phase, with the Doris Duke Charitable Foundation supporting partnerships in Ethiopia, Ghana and Mozambique to replicate and scale up measures that had proven successful in the earlier phase.

Central to both phases was the integration of “implementation research,” or the study of how stakeholders within health systems apply new knowledge and practices, into each project. Researchers were embedded within implementing teams and tasked with examining the barriers and facilitators to the interventions’ successes. Throughout the life cycle of each project, the researchers’ findings were used to assess the efficacy of the interventions and inform any necessary strategic pivots.

Their findings also formed the basis for the articles featured in the latest journal supplement. Three of these pieces analyze how effectively the African Health Initiative’s primary interventions—support for mainstreaming implementation research, strengthening data generation and analysis, and building or enhancing staff supervision and mentoring techniques—were incorporated into health care systems in phase 2 countries. The remaining articles explore the impact of those interventions on specific aspects of health care systems in each country.

Despite the varied content and geographic contexts covered, several common themes emerge across the articles. First, the integration of implementation research has a demonstrably positive impact on the resilience and responsiveness of health care systems. It provides a framework for all stakeholders to assess the performance of key functions, identify issues and devise solutions. Second, the generation and analysis of data—health information management—are critical to the optimal functioning of health systems. Accurate and timely data equips decision-makers with the information they need to create effective policies, ensures that resources are allocated where they are needed most, and enables administrators and health care workers to monitor key health programs in real time. Third, routinized mentorship and supervision is essential to maintaining fidelity to newly introduced practices. The benefits of one-off trainings wane over time, whereas frequent refreshers and supervisory check-ins help staff adhere to standards and practices. Finally, regular engagement among all stakeholders improves health system performance and the uptake of new practices. These frequent interactions build trust, broaden perspectives, and create opportunities for collaborative decision making.

Most of the work funded by the African Health Initiative will end in 2023, and the last project is set to conclude in 2024. Though the funding has come to an end, the work and partnerships established in each country will continue. As the initiative winds down after 15 years, the Doris Duke Charitable Foundation is proud to have helped build a foundation for responsive, resilient and sustainable health systems in communities across sub-Saharan Africa. It is our sincere hope that the lessons learned throughout, diligently captured in these articles, will inform subsequent efforts to further strengthen health systems in the region and beyond.

Direct links to each of the articles and a brief summary can be found below.


Global Health: Science and Practice 2022 | Volume 10 | Supplement

Learning Health Systems to Bridge the Evidence-Policy-Practice Gap in Primary Health Care: Lessons From the African Health Initiative 

Colin Baynes, Lola Adedokun, John Koku Awoonor-Williams, Lisa R. Hirschhorn 

The authors provide a brief history of the African Health Initiative and introduce the articles of the Global Health: Science and Practice journal supplement, highlighting the importance of evidence-based interventions (EBI) in global health and summarizing key takeaways.  

The African Health Initiative’s Role in Advancing the Use of Embedded Implementation Research for Health Systems Strengthening

Abdul Ghaffar, Livia Dal Zennaro, Nhan Tran 

The authors explore how embedded implementation research (EIR) can inform and improve programs and policies and outline how AHI used EIR to improve health systems in sub-Saharan Africa. Effective EIR initiatives require engaging many stakeholders and ensuring that efforts are responsive to community needs. 

Embedding Research on Implementation of Primary Health Care Systems Strengthening: A Commentary on Collaborative Experiences in Ethiopia, Ghana, and Mozambique

African Health Initiative Partnership Collaborative for Embedded Implementation Research 

Through a review of 30 case studies and extensive interviews, the authors detail the core features of implementation research across AHI partnerships and identify the factors that influenced the approach’s effectiveness in producing meaningful and lasting change in health systems.  

Barriers and Facilitators to Data Use for Decision Making: The Experience of the African Health Initiative Partnerships in Ethiopia, Ghana and Mozambique

African Health Initiative Partnership Collaborative for Data Use for Decision Making 

The authors examine the health information systems (HIS) approach used by each country and the factors—such as leadership engagement, external policies and performance incentives—that influenced the success of HIS strengthening interventions.  

Improving Primary Care Quality Through Supportive Supervision and Mentoring: Lessons From the African Health Initiative in Ethiopia, Ghana, and Mozambique

AHI Partnership Collaborative for Supportive Supervision and Mentoring 

The authors describe how partnerships in each country applied supportive supervision and mentoring (SSM) strategies at primary care facilities and how these strategies influenced the quality of care. The article concludes with potential recommendations to improve SSM efficacy in other contexts.  

“You Can’t Look at an Orange and Draw a Banana”: Using Research Evidence to Develop Relevant Health Policy in Ghana

Ayaga A. Bawah, Adriana A.E. Biney, Pearl Kyei 

Ghana has long embraced implementation research and the use of evidence-based interventions to inform health care policy. However, bridging the gap between policymakers’ needs and researchers’ approaches has proven challenging. The authors identify the source of this disconnect and provide suggestions for how it might be overcome.  

The Use of Research for Health Systems Policy Development and Implementation in Mozambique: A Descriptive Study

Maria Isabel Cambe, Carlos Botão, Janeth Dulá, Elídio Muamine, Sérgio Mahumane, Carla Alberto, Sérgio Chicumbe 

The authors examine the barriers to effective use of health research in policy and decision making in Mozambique. They identify opportunities to generate more locally relevant research and promote a greater use of research by policymakers.  

Drivers and Barriers to Improved Data Quality and Data-Use Practices: An Interpretative Qualitative Study in Addis Ababa, Ethiopia

Hibret Tilahun, Biruk Abate, Hiwot Belay, Abebaw Gebeyehu, Mohammed Ahmed, Akiliu Simanesew, Wondimu Ayele, Afrah Mohammedsanni, Barbara Knittel, Yakob Wondarad 

The authors outline a number of factors—including leadership engagement, performance incentives and regular mentorship—that have improved data quality and use in Ethiopia. They also detail the barriers, such as negative attitudes toward data or limited technical capacity, that have impeded quality data generation and use.  

Primary Health Care Management Effectiveness as a Driver of Family Planning Service Readiness: A Cross-Sectional Analysis in Central Mozambique

Stephen Pope, Orvalho Augusto, Quinhas Fernandes, Sarah Gimbel, Isaías Ramiro, Dorlim Uetela, Stélio Tembe, Meredith Kimball, Mélia Manaca, C. Leigh Anderson, Sérgio Chicumbe, Kenneth Sherr 

The authors examine the relationship between primary care facility management and the quality of care provided. They determine that a higher degree of management effectiveness is associated with improved service delivery, and identify barriers and opportunities to strengthen management capacity.  

Health Policy and Systems Research Capacities in Ethiopia and Ghana: Findings From a Self-Assessment

Viroj Tangcharoensathien, Morankar Sudhakar, Zewdie Birhanu, Gelila Abraham, Ayaga Bawah, Pearl Kyei, Adriana Biney, Zubin Cyrus Shroff, Woranan Witthayapipopsakul, Warisa Panichkriangkrai 

Both Ghana and Ethiopia struggle to independently generate research to inform health policy, largely relying on external funding or studies from other countries. The authors examine why that is the case and issue several recommendations to strengthen health policy and systems research capacity in each country.  

Maternal Service Coverage and Its Relationship to Health Information System Performance: A Linked Facility and Population-Based Survey in Ethiopia

Abebaw Gebeyehu Worku, Hibret Alemu Tilahun, Hiwot Belay, Afrah Mohammedsanni, Naod Wendrad, Biruk Abate, Mesoud Mohammed, Mohammed Ahmed, Yakob Wondarad, Meskerem Abebaw, Wubshet Denboba, Frehiwot Mulugeta, Shemsedin Oumer, Amanuel Biru

The authors explore whether health data quality and usage by decision makers has an influence on maternal and child service coverage. They conclude that although HIS performance in Ethiopia remains suboptimal, it has had a positive association with service uptake and quality.  

Applying the Consolidated Framework for Implementation Research to Identify Implementation Determinants for the Integrated District Evidence-to-Action Program, Mozambique

Celso Inguane, Caroline Soi, Sarah Gimbel, Nélia Manaca, Isaías Ramiro, Florência Floriano, Georgina de Castro, Orvalho Augusto, Stélio Tembe, James Pfeiffer, Quinhas Fernandes, Kenneth Sherr 

The Integrated District Evidence-to-Action (IDEA) program aims to reduce mortality in children under 5 through an implementation research approach that combines regular health systems readiness assessments, audit and feedback meetings, and support—both training and financial—to implement facility-level action plans. The authors conduct a robust analysis to identify facilitators and barriers to implementation of IDEA.  

Maternal and Child Health Care Service Disruptions and Recovery in Mozambique After Cyclone Idai: An Uncontrolled Interrupted Time Series Analysis 

Quinhas Fernandes, Orvalho Augusto, Sérgio Chicumbe, Laura Anselmi, Bradley H. Wagenaar, Rosa Marlene, Sãozinha Agostinho, Sarah Gimbel, James Pfeiffer, Celso Inguane, Dorlim Moiana Uetela, Jonny Crocker, Isaías Ramiro, Benigna Matsinhe, Stélio Tembe, Naziat Carimo, Stephen Gloyd, Ivan Manhiça, Esperança Tavede, Priscilla Felimone, Kenneth Sherr

Cyclone Idai caused significant disruptions to maternal and child health (MCH) services in Mozambique. However, MCH utilization rates recovered within three months after the storm. The authors examine Idai’s impact on key services and why those services were able to recover relatively quickly, highlighting the country’s experience with implementation research as a key factor. 

Lessons Learned From the Capacity-Building and Mentorship Program to Improve Health Information Systems in 11 Districts of Ethiopia

Hiwot Belay, Afrah Mohammedsanni, Abebaw Gebeyehu, Hibret Alemu, Naod Wendrad, Biruk Abate, Wubshet Denboba, Frehiwot Mulugeta, Shemsedin Omer, Barbara Knittel 

The Capacity-Building and Mentorship Program (CBMP) is an academic-government partnership that aims to improve data collection quality and analysis in regional health bureaus and zonal health departments in Ethiopia. The authors outline CBMP’s impact on data quality and use, highlighting various factors and barriers to the program’s success.  

Using Health Systems and Policy Research to Achieve Universal Health Coverage in Ghana 

John Koku Awoonor-Williams, Stephen Apanga, Ayaga A. Bawah, James F. Phillips, Patrick S. Kachur 

The authors examine Ghana’s experience with using implementation research to guide the development and expansion of its primary care system. Additionally, they detail challenges associated with the rollout of the country’s National Health Insurance Scheme and the systemic constraints that poor populations face in accessing health care.  

Health System Resilience: Withstanding Shocks and Maintaining Progress

Agnes Binagwaho, Dennis Hirwe, Kedest Mathewos 

The authors explore the factors that contribute to a health system’s ability to withstand external shocks, emphasizing the positive role that implementation research can play in promoting responsiveness to community needs.