Abstract Background The current generation of 1.3 billion adolescents (10–19-year-olds), most of whom live in low- and middle-income countries, face large and growing mental health problems. Collective action that could lead to significant improvement in adolescent mental health and well-being (AMH) remains limited. We analyse the factors shaping the global prioritization of AMH for funding and action and reflect on a way forward. Methods We triangulate data from interviews with key informants knowledgeable in AMH; focus group discussions with youth representatives who are mental health advocates, some with lived experience of mental ill-health; and document review. We collected the qualitative data from 2021 to 2023, followed by thematic analysis and stakeholder consultations. Results We identify four themes which shape the global prioritization of AMH. First, prevailing interpersonal and institutional stigma and discrimination directed against adolescents with mental health problems hamper attention to AMH. Second, limited data on the burden of mental health problems and evidence of what works have led to the perception among decision-makers that AMH is an intractable problem. Third, diverse ways of framing AMH are often viewed as a sign of weak alignment rather than as opportunities for coalition-building. Fourth, a wide variety and increasing number of stakeholders are involved in AMH, while the stakeholder landscape remains fragmented, inhibiting coalition-building for AMH. Conclusions To overcome the barriers that currently impede the prioritization of AMH, we recommend that (1) stakeholders conduct an adolescent-led consultative process to develop an “umbrella framing”, supported by common metrics, (2) advocates use existing global platforms to shape the political priority for AMH, (3) decision-makers, funders and research partners invest in meaningful engagement of adolescents (with lived experience), researchers and implementing partners (4) identify a leadership, governance and accountability structure for a global coalition that could transform AMH and (5) conduct context-specific analyses to inform coalition-building nationally.

Dashboards and other interactive web-based data visualisation tools are increasingly being developed to inform health policy at global, national, and subnational levels. Dashboards aim to make policy-relevant data accessible to support decision making, priority setting, policy development, implementation, and monitoring and evaluation for those responsible for these functions. However, evidence on how well dashboards fulfil these functions is scarce. In this Viewpoint, we explore the development of dashboards on topics related to children's health and experiences of actors using dashboards in Ghana, India, and South Africa. Although some dashboards are useful for strategic and operational planning, public information, and accountability, many are not well suited for their designated purpose or not integrated into existing processes. Data unavailability, infrequent updates, and poor interoperability within data ecosystems often constrain the potential of dashboards. Governance frameworks limit incentives to improve data quality by restricting data to monitoring roles or failing to promote the active use of data. Although dashboard creation can uncover data-related problems and facilitate collaboration among actors to solve these problems, the development process is more time and resource intensive than many actors anticipate. We highlight the aspects of design, functionality, and context that influence the usefulness of dashboards, discuss practical challenges and opportunities, and offer recommendations to guide the development and implementation of data-driven tools for health policy initiatives.

Community engagement is widely acknowledged as critical to Everyday Health Systems Resilience (EHSR), but there are few empirical case studies that examine ‘how’ and ‘why’ initiatives at the community-health system interface unfold over time. In this paper, we present the experience of the Ocean View Community Care Centre (CCC), a community-led response to the Covid-19 pandemic in the Western Cape, South Africa. Using a five-year long embedded research approach, we drew on traditions of participatory action research and organisational ethnography. Data collection included documenting observations and reflections in a research diary during implementation, in-depth interviews, focus group discussions (using photo-elucidation methods) and a WhatsApp archive. In addition, a series of sensemaking discussions with academic research team members were done. Our analysis draws on and extends the EHSR framework which characterises resilience as an emergent phenomena of health systems. We consider the CCC as a potentially transformative resilience strategy as it nurtured system capacities (networks and relationships) that could support future responses to shocks. Our findings demonstrate how relationships and networks can generate resources (hardware and software) and nurture system capacities for EHSR, but also highlights that relationships and networks on their own are not enough. The CCC experience offers the notion of boundary spanning (not yet explored in the EHSR literature) to shed light on how the energy of these networks needs to be harnessed by individuals who have a ‘passport of legitimacy’ to work across networks, suggesting that boundary spanners are themselves important in nurturing system capacities for resilience.

Working with men and boys is central to improving sexual and reproductive health and rights and contributes to gender equality and social justice. Focusing on two behaviour change interventions ("One Youth Can" and "SKILLZ Guyz"), embedded within a national HIV programme ("My Journey"), this qualitative, exploratory study explored the contextual and organizational realities faced by peer facilitators in implementing these two interventions and what it would take to integrate a gender-transformative approach into their practice. The research, conducted in South Africa, used three data sources: a curriculum gender analysis, observations of both interventions and capacity strengthening sessions with peer facilitators. The study found that facilitators have to manage an array of contextual challenges. The programmatic context in which they work is dominated by the need to meet quantitative targets, leaving the capacity strengthening and mentoring needs of the facilitators - and their own lived experiences insufficiently addressed. Our research confirms the pivotal role peer facilitators can play in implementing gender-transformative approaches with adolescent boys and men in South Africa, but recommends that their practice be accompanied by sustained capacity strengthening and organisational support to address the unequal systems of gender and intersecting power relations in the contexts in which they work and live.

This study explores the factors underlying the prioritisation of adolescent and youth mental health policy in South Africa, or lack thereof, from the perspective of health policy actors and youth advocates. In-depth interviews were conducted with 34 key informants including researchers, civil society and government policy actors and a focus group with seven youth advocates, aged 18─24 years. Data were analysed thematically drawing on an adapted version of a policy prioritisation framework. The analysis revealed several barriers to prioritisation, including: a lack of policy community cohesion, inadequate leadership, insufficient collaboration with adolescents and young people and those with lived experience, evidence gaps, a fragmented policy landscape, and a lack of simple, scalable solutions. However, a number of opportunities were also identified: dedicated and passionate actors, new evidence, and contextual factors which have raised public awareness and provided opportunities for change, such as COVID-19 and the introduction of National Health Insurance. Adolescent and youth mental health has not received the political attention necessary to ensure that action is taken to enhance and protect the mental health of young South Africans. More purposeful efforts to unite the adolescent mental health community and coordinate research, advocacy, policy and implementation efforts are needed to address these challenges. This research provides insight into the current state of adolescent and youth mental health policy in South Africa and potential actions to strengthen adolescent mental health policy development and implementation.

This study focuses on two key initiatives spearheaded by the Ministry of Health in Ethiopia, which have contributed to improving gender equality in primary healthcare (PHC): (1) a gender mainstreaming manual; and (2) the PHC response to gender-based violence (GBV). This case was selected as a promising practice because of the significant government leadership and ownership involved in advancing gender integration within a government health system. Based on in-depth analyses of interviews and published materials, it documents the context, a number of enabling factors and challenges encountered, and some of the outcomes achieved and lessons learned, including those that might be transferable to other contexts.

Background In 2015, Uganda joined the Global Financing Facility (GFF), a Global Health Initiative for Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH). Similar initiatives have been found to be powerful entities influencing national policy and priorities in Uganda, but few independent studies have assessed the GFF. Objective To understand the policy process and contextual factors in Uganda that influenced the content of the GFF policy documents (Investment Case and Project Appraisal). Methods We conducted a qualitative policy analysis. The data collection included a document review of national RMNCAH policy documents and key informant interviews with national stakeholders involved in the development process of GFF policy documents (N = 16). Data were analyzed thematically using the health policy triangle. Results The process of developing the GFF documents unfolded rapidly with a strong country-led approach by the government. Work commenced in late 2015; the Investment Case was published in April 2016 and the Project Appraisal Document was completed and presented two months later. The process was steered by technocrats from government agencies, donor agencies, academics and selected civil society organisations, along with the involvement of political figures. The Ministry of Health was at the center of coordinating the process and navigating the contestations between technical priorities and political motivations. Although civil society organisations took part in the process, there were concerns that some were excluded. Conclusion The learnings from this study provide insights into the translation of globally conceived health initiatives at country level, highlighting enablers and challenges. The study shows the challenges of trying to have a ‘country-led’ initiative, as such initiatives can still be heavily influenced by ‘elites’. Given the diversity of actors with varying interests, achieving representation of key actors, particularly those from underserved groups, can be difficult and may necessitate investing further time and resources in their engagement.

Background Burkina Faso joined the Global Financing Facility for Women, Children and Adolescents (GFF) in 2017 to address persistent gaps in funding for reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N). Few empirical papers deal with how global funding mechanisms, and specifically GFF, support resource mobilisation for health nationally. Objective This study describes the policy processes of developing the GFF planning documents (the Investment Case and Project Appraisal Document) in Burkina Faso. Methods We conducted an exploratory qualitative policy analysis. Data collection included document review (N = 74) and in-depth semi-structured interviews (N = 23). Data were analysed based on the components of the health policy triangle. Results There was strong national political support to RMNCAH-N interventions, and the process of drawing up the investment case (IC) and the project appraisal document was inclusive and multi-sectoral. Despite high-level policy commitments, subsequent implementation of the World Bank project, including the GFF contribution, was perceived by respondents as challenging, even after the project restructuring process occurred. These challenges were due to ongoing policy fragmentation for RMNCAH-N, navigation of differing procedures and perspectives between stakeholders in the setting up of the work, overcoming misunderstandings about the nature of the GFF, and weak institutional anchoring of the IC. Insecurity and political instability also contributed to observed delays and difficulties in implementing the commitments agreed upon. To tackle these issues, transformational and distributive leaderships should be promoted and made effective. Conclusions Few studies have examined national policy processes linked to the GFF or other global health initiatives. This kind of research is needed to better understand the range of challenges in aligning donor and national priorities encountered across diverse health systems contexts. This study may stimulate others to ensure that the GFF and other global health initiatives respond to local needs and policy environments for better implementation.

Engaging men and boys in sexual and reproductive health and rights (SRHR) and doing so in a way that challenges harmful masculinities, is both neglected and vital for improving the SRHR of both women and men. To address this gap, WHO commissioned a global research priority setting exercise on masculinities and SRHR. The exercise adapted the quantitative child health and nutrition research initiative priority setting method by combining it with qualitative methods. Influenced by feminist and decolonial perspectives, over 200 diverse stakeholders from 60 countries across all WHO regions participated. The exercise forges a collaborative research agenda emphasising four key areas: gender-transformative approaches to men's and boys’ engagement in SRHR, applied research to deliver services addressing diversity in SRHR among men and women and to generate gender-equality, research designs to support participation of target audiences and reach to policy makers, and research addressing the priorities of those in low-income and middle-income countries.

Adolescent health is being increasingly featured in global policy discourse on sustainable development. Despite global calls for more joined up working across relevant sectors, there is less known on how to effectively co-opt other sectors for programming of globally recommended adolescent health measures. This paper aimed to assess multisector programming of nutrition versus tobacco control interventions for adolescents in Pakistan from a political economy lens. Both nutrition programming and tobacco control rely on multi-sectoral programming and are one of the foremost areas for adolescent health needs in Pakistan. Data was drawn from 84 key informant interviews across government stakeholders, development partners, civil society organizations, experts and youth groups, review of policy and programming resources and published literature. The study scope was confined to exploring the pathway of programming and early implementation does not extend to evaluation of implementations. Existing frameworks of multi-sector governance were adapted and progress was assessed against i) issue framing, ii) stakeholder coalitions, iii) resourcing and iv) coordination platforms, to understand challenges and opportunities for an effective multi-sector response. Our analysis found important commonalities as well as differences across both nutrition and tobacco control programming in Pakistan. First, adolescents had a weak constituency within nutrition efforts confined to under-nutrition interventions for reproductive health and a gendered nuancing overlooking needs of boys but have featured historically in national Tobacco control frameworks. Second, lack of framing of social-behavioural perspectives in national response was commonly seen for both adolescent Nutrition as well as Tobacco Control constraining coalitions with new stakeholder groups such as youth initiatives, local government, sports, education, and entertainment that are necessary for lifestyle changes in adolescents. Third, Nutrition had opportune multi-sector platforms of the SUN networks available for programming whereas Tobacco Control situated within the health ministry struggled with mandate to steer multi-sector programming and unlock resources held by other sectors. Fourth, we found that horizontal coordination across sectors itself requires dedicated resourcing and capacity which was overlooked. The Pakistan case study adds to contextual insights on success and failure of multisector governance for nutrition providing an analytical contrast with a similar multi-sector issue of tobacco control. We conclude that the process of how multi-sector programming for adolescent nutrition is brought about within countries is equally important as the prescriptive content of globally advocated interventions. We also identified key elements of a pathway to more effective programming that include attention to i) inclusive framing for its domino effect on coalition building, ii) ensuring diversity within core coalitions; iii) an organisational home outside the health sector for programming across sectors; iv) dedicated resourcing for impactful coordination and oversight of multi-sector programming.

An equity lens to maternal health has typically focused on assessing the differences in coverage and use of healthcare services and critical interventions. While this approach is important, we argue that healthcare experiences, dignity, rights, justice, and well-being are fundamental components of high quality and person-centred maternal healthcare that must also be considered. Looking at differences across one dimension alone does not reflect how fundamental drivers of maternal health inequities—including racism, ethnic or caste-based discrimination, and gendered power relations—operate. In this paper, we describe how using an intersectionality approach to maternal health can illuminate how power and privilege (and conversely oppression and exclusion) intersect and drive inequities. We present an intersectionality-informed analysis on antenatal care quality to illustrate the advantages of this approach, and what is lost in its absence. We reviewed and mapped equity-informed interventions in maternal health to existing literature to identify opportunities for improvement and areas for innovation. The gaps and opportunities identified were then synthesised to propose recommendations on how to apply an intersectionality lens to maternal health research, programmes, and policies.

Background Community health is key for improving Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition (RMNCAH-N). However, how community health supports integrated RMNCAH-N service delivery in francophone West Africa is under-researched. Objective We examined how six francophone West African countries (Burkina Faso, Côte d’Ivoire, Guinea, Mali, Niger, and Senegal) support community health through the Global Financing Facility for Women, Children and Adolescents (GFF). Methods We conducted a content analysis on Investment Cases and Project Appraisal Documents from selected countries, and set out the scope of the analysis and the key search terms. We applied an iterative hybrid inductive-deductive approach to identify themes for data coding and extraction. The extracted data were compared within and across countries and further grouped into meaningful categories. Results In country documents, there is a commitment to community health, with significant attention paid to various cadres of community health workers (CHWs) who undertake a range of preventive, promotive and curative roles across RMNCAH-N spectrum. While CHWs renumeration is mentioned, it varies considerably. Most community health indicators focus on CHWs’ deliverables, with few related to governance and civil registration. Challenges in implementing community health include poor leadership and governance and resource shortages resulting in low CHWs performance and service utilization. While some countries invest significantly in training CHWs, structural reforms and broader community engagement are lacking. Conclusions There is an opportunity to better prioritize and streamline community health interventions, including integrating them into health system planning and budgeting, to fully harness their potential to improve RMNCAH-N.

Background The Global Financing Facility (GFF) supports national reproductive, maternal, newborn, child, adolescent health, and nutrition needs. Previous analysis examined how adolescent sexual and reproductive health was represented in GFF national planning documents for 11 GFF partner countries. Objectives This paper furthers that analysis for 16 GFF partner countries as part of a Special Series. Methods Content analysis was conducted on publicly available GFF planning documents for Afghanistan, Burkina Faso, Cambodia, CAR, Côte d’Ivoire, Guinea, Haiti, Indonesia, Madagascar, Malawi, Mali, Rwanda, Senegal, Sierra Leone, Tajikistan, Vietnam. Analysis considered adolescent health content (mindset), indicators (measure) and funding (money) relative to adolescent sexual and reproductive health needs, using a tracer indicator. Results Countries with higher rates of adolescent pregnancy had more content relating to adolescent reproductive health, with exceptions in fragile contexts. Investment cases had more adolescent content than project appraisal documents. Content gradually weakened from mindset to measures to money. Related conditions, such as fistula, abortion, and mental health, were insufficiently addressed. Documents from Burkina Faso and Malawi demonstrated it is possible to include adolescent programming even within a context of shifting or selective priorities. Conclusion Tracing prioritisation and translation of commitments into plans provides a foundation for discussing global funding for adolescents. We highlight positive aspects of programming and areas for strengthening and suggest broadening the perspective of adolescent health beyond the reproductive health to encompass issues, such as mental health. This paper forms part of a growing body of accountability literature, supporting advocacy work for adolescent programming and funding.

The role of the emergency medical service (EMS) is changing globally as ambulance crews respond to a shifting burden of disease, as well as societal stressors such as violence and inequality. New ways of thinking about how to provide emergency care are required to shift EMS from a role primarily focused on clinical care and transporting patients to hospital. In this paper, we present the experience of the Philippi Project (PP), an innovative community-based model of care developed by front line ambulance crews in a low-income neighbourhood in Cape Town, South Africa. Our insights were developed through observational, interview and document review work, within an overall embedded research approach. Our analysis draws on the everyday health systems resilience (EHSR) framework, which sees resilience as an emergent process that may be stimulated through response to stress and shock. Responses take the form of absorptive, adaptive or transformative strategies and are underpinned by system capacities (cognitive, behavioural and contextual). We consider the PP as a potentially transformative resilience strategy, defined as a new way of working that offered the promise of long-term health system gains. We found that the PP's initial development was supported by a range of system capacity attributes (such as the intentional development of relationships, a sense of collective purpose and creating spaces for constructive sense-making). However, the PP was hard to sustain over time because emergent ways of working were undermined both by other capacity attributes rooted in pre-existing organizational routines and two contextual shocks (Coronavirus and a violent incident). The paper adds a new empirical contribution to the still-small EHSR literature. In addition, the PP experience offers globally relevant lessons for developing community-based models of EMS care. It demonstrates that front line staff can develop creative solutions to their stressful daily realities, but only if space is created and protected.

Rationale: Understanding what young adults and other key stakeholders find acceptable for HIV prevention interventions and reasons explaining acceptability or lack thereof is crucial for intervention developers and implementers in sub-Saharan Africa (SSA). Higher acceptability of health and social interventions can improve intervention uptake and effectiveness. Objectives: This paper aims to aggregate and synthesise the evidence on the acceptability of HIV prevention interventions for young adults in SSA, published over the past twelve years. Methods: In line with PRISMA guidelines, we conducted a systematic mapping review to identify studies assessing the acceptability of HIV prevention interventions with young adults aged 10-24 in SSA, published between 2010 and 2022. We employed descriptive syntheses to aggregate and present study characteristics, methodologies, and findings on overall intervention acceptability. An inductive thematic analysis of quantitative and qualitative findings across studies was then conducted to highlight reasons for the acceptability or unacceptability of interventions among young adults and other stakeholders. Results: The review identified 32 studies assessing young adults' acceptability of HIV prevention interventions. Fourteen studies also explored the acceptability of other stakeholders, such as caregivers, teachers, and healthcare workers. Overall reported acceptability was high. Of the 18 studies that provided a quantitative assessment based on the proportion of participants that found the intervention acceptable, only one study reported acceptability below 50%. The findings of the thematic analysis identified the following seven key factors shaping acceptability: ease of use; intervention understanding; intervention costs; perceived positive effects; perceived negative effects; relevance to young adults' needs and context; and social factors shaping acceptability. Conclusion: The review highlights the importance of collecting and aggregating information on the acceptability of HIV prevention interventions in Africa to inform future intervention development. It also points to factors developers and implementers of HIV prevention services and programmes should consider. However, our review also exposes gaps in the literature. More research is needed to investigate the acceptability of different stakeholders beyond end-users, the acceptability of integrated interventions, and the development of more robust theoretical frameworks and measurement tools. Understanding what influences the acceptability of interventions among young people and other key individuals will better equip researchers and practitioners to meet their needs and improve opportunities for the transition to adulthood.

Kéfilath Bello and colleagues argue that building on promising practices to develop more sustainable strategies to advance gender equality will help African countries respond to future crises

The covid-19 emergency may have been declared over, but its effects are not. Pre-existing inequities worsened during the pandemic, and the crisis has hardened societal fault lines. Sex and gender mark many of these. Early on, sex and gender featured visibly as men seemed at higher risk of infection and hospital admission, andwomenof longer term illness and caregiving burdens. Over time, it became evident that covid-19 was exacerbating multiple and intersecting vulnerabilities, with substantial effects on women and girls: increased care burdens, amplified gender based violence during lockdowns, catastrophic drops in income and employment for women and families, disrupted essential health services, and school closures that heightened risk of unintended pregnancies and permanent dropouts.