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Introduction: Accountability is crucial for improved functionality of health systems and can be ensured through community participation in health governance. To engage the community in the governance of the local health system, health facility governing committees (HFGCs) have been implemented in several low-income and middle-income countries including Tanzania. However, the effect of HFGCs on health system performance is not well studied. The aim of this study was to investigate the relationship between the functionality of the HFGCs and health system performance in 180 districts of mainland Tanzania, and to assess whether this relationship varies between dispensaries, health centres and hospitals.

Methods: We conducted an ecological study in which the studied outcome was health system performance. The main independent variable was functionality of HFGCs, that is, to what extent these committees reflect the concerns of and connect back to the community. Other explanatory variables included staff availability, location of the facility, gender of the manager of the facility and ownership of the facility. Data on all of the variables were retrieved from the Star Rating Assessment of 2017/2018, measured as mean proportions of all facilities in the districts. The analyses included linear regression for all facility levels combined, as well as for the levels of facility separated (dispensaries, health centres and hospitals).

Results: We found a positive relationship between the functionality of the HFGCs and health system performance (β=0.53; 95% CI=0.47 to 0.60). The relationship was stronger for dispensaries (β=0.56; 95% CI=0.50 to 0.63) compared to health centres (β=0.39; 95% CI=0.33 to 0.44) and hospitals (β=0.23; 95% CI=0.15 to 0.31).

Conclusions: Districts that have functional HFGCs tend to have better health system performance than others. This relationship is stronger in dispensaries compared to health centres and hospitals. Therefore, we believe the district authorities should allocate resources to strengthen the HFGCs.

Background: In 2014, the Zambian government introduced the Comprehensive Sexuality Education (CSE) framework, decentralising its implementation from the national to the provincial administration. The provincial structures of the Ministries of Health and Education play an important role in providing technical, policy direction and coordination support. However, little research has focused on the role of CSE collaboration at the provincial level.

Objectives: This study sought to explore multisectoral collaboration dynamics influencing the implementation of the CSE framework at the provincial level in Zambia. Methods: This qualitative study involved 29 interviews with diverse stakeholders at the provincial level such as government departments (health, education, etc.), private sector, religious and traditional leaders involved in CSE implementation. We used reflexive thematic analysis, guided by an integrative collaborative governance framework.

Results: The findings were grouped under collaboration dynamics domains: principled engagement, shared motivation, and capacity for joint action. Barriers to principled engagement included provincial structures and their mandate, exclusion or sidelining of certain actors, inadequate financial transparency, and weak formal relations. Shared motivation included collective understanding of the purpose, a supportive policy environment and consensus in adapting the CSE framework. Capacity for joint action efforts included collaborative training of teachers, joint monitoring, and collaborative to address SRHR challenges.

Conclusion: This study highlights challenges limiting meaningful engagement, exclusion of some actors, financial constraints, and weak coordination, which hinder collaboration. There is need for enhancing provincial leadership capacity to effectively coordinate stakeholders through enforcement of transparent resource management, collective planning, implementation and monitoring for effective CSE delivery.

Introduction: Environments where people live and work shape resources and opportunities available to them and studying healthcare access in relation to people’s living environments helps in understanding structural factors beyond individual factors. This is especially relevant for many Adivasi communities whose lives are closely connected with forests.

Methods: We used the critical interpretive synthesis method, a flexible, critical and iterative approach to literature synthesis. We conceptualised health and healthcare access in relation to neighbourhood environment and used this lens to examine healthcare access in Adivasi communities living in forest neighbourhoods in India.

Results: We developed a lens of neighbourhood as a physical and social environment and used it to build a conceptual framework describing forest neighbourhoods in India. We describe forest neighbourhoods in terms of their built and social environment. The availability of mobile networks, condition of roads, flooding of streams during rains and the forms of transport available constitute the built environment. There are two important components of the social environment, first is the connection of the Adivasi people with the forest and second is the institutional environment comprising of different actors working in the forest neighbourhood. The life of Adivasi people is connected with the forest through their livelihood, nutrition, physical and mental well-being and their ecological knowledge about the forest from their lived experience. The institutional environment consists of different actors that shape the built and social environment that comprise the government institutions, private for-profit providers, civil society organisations, traditional healers and the forest department.

Conclusion: While working on Adivasi health, it is critical to consider their connection with the forest. Exploring forest neighbourhoods as physical and social environments can help examine distribution of public services and how they are shaped by external policies and actors working in the neighbourhood. This could shift the focus of Adivasi health and healthcare interventions away from the current emphasis on individual-level health interventions. 

Background: With increasing conflict, fragility, and emergencies in many countries, health systems are being frequently weakened and require support and strengthening. To ensure the provision of lifesaving interventions while improving national health systems, the humanitarian–development nexus presents a policy solution to bridge the divide between humanitarian and development actors. Sudan represents an interesting case of the nexus of adoption in the context of protracted emergencies, a volatile political scene, and complex economic and partnership dynamics. This study aimed to explore the understanding and adoption process of the nexus approach to health systems strengthening in Sudan.

Methods: We conducted a policy analysis based on seven qualitative interviews conducted in 2022 with informants from varying humanitarian and development entities.

Results: Our findings revealed uncertainty surrounding the meaning and practicalities of the nexus, despite a consensus on its importance. At the same time, the introduction process was driven by global partners, the Government of Sudan’s adoption of the nexus, and the presence of relevant coordination mechanisms within the health sector, which facilitated the advancement of the nexus. However, the humanitarian and development actors expressed conflicting values and disagreements about the use of the financial management, procurement, and information components of the national health system.

Conclusion: Sudan’s health partners have implemented various nexus-based practices to strengthen national health system capacities. However, the nexus approach has faced challenges due to conceptual ambiguities and inconsistent implementation. We call for the advancement of guidance and dialog on the approach, emphasizing the importance of ownership, coordination, and flexibility, with the belief that the humanitarian–development divide can be further bridged.

People living with human immunodeficiency virus (PLHIV) often navigate complex and vulnerable circumstances shaped by intersecting social identities that influence their experiences with human immunodeficiency virus (HIV) infection, healthcare, and support services. This qualitative study explored how PLHIV in Sweden perceive and experience healthcare and social support. It draws on 32 in-depth interviews conducted in 2019, 2021, and 2024 with participants aged 20–65 years. Three central themes were identified through thematic analysis. The first theme, "Carrying Many Burdens: Multiple Vulnerabilities, Overlapping Conditions, and Socioeconomic Hardship", how overlapping identities, health issues, and financial hardship compound vulnerability. Second, "Varying Attitudes and Practices in Healthcare Settings", reflect inconsistent and sometimes problematic encounters with healthcare systems. The third theme, "Nongovernmental Organizations Support is Valuable but Limited", emphasizes the importance of support while revealing its inadequacy in reaching everyone and meeting all needs. These findings highlight the multifaceted vulnerabilities faced by PLHIV in Sweden and point to significant gaps in both healthcare and social support systems. Addressing these challenges calls for coordinated efforts across the structural, institutional, and individual levels.

This paper investigates municipal government initiatives targeting ‘local development’ and community sustainability in municipal peripheries in rural Västerbotten, Sweden. Analysing planning documents, we identify 142 initiatives from 2022 to 2023 using a social determinants of health (SDH) framework, particularly focusing on labour, business development, technology adoption, municipality-business collaboration, supporting village associations, and alternative modes of service delivery. We conclude that municipalities are attempting to support individual villages and place-based communities in determining their own development paths across all SDH domains, suggesting a shift from central-place to decentralised planning models.

Introduction: Evidence suggests that migrants are at a higher risk of poor sexual health compared to non-migrants. However, this vulnerability may vary depending on their socio-demographic backgrounds and experiences. This study aimed to describe the prevalence of poor self-rated sexual health, its distribution, and associated risk factors among migrants in Sweden.

Methods: This study is a secondary analysis of the 2018 Migrants’ Sexual and Reproductive Health and Rights (MSRHR-2018) survey, which included a total of 1,118 migrants enrolled in language programmes. Data were analysed with descriptive, bivariate, and multivariable regression analyses.

Results: About 19% of participants reported poor self-rated sexual health. The latter was associated with older (>44 years) age (PR:1.83; 95% CI:1.08, 3.10), low educational attainment (PR: 1.80; 95% CI: 1.04, 3.11), repeated difficulty in making ends meet (PR: 1.51; 95% CI:1.01, 2.26), being not at all or not particularly open about one’s sexual orientation (PR: 1.62; 95% CI: 1.06, 2.49), lifetime experience of discrimination (PR: 1.61; 95% CI: 1.09, 2.39), and refraining from seeking sexual and reproductive health (SRH) services despite felt needs (PR: 1.87; 95% CI: 1.22, 2.85) remained associated with poor self-rated sexual health.

Conclusion: This study highlights the prevalence of poor self-rated sexual health among migrants, while revealing significant disparities across specific subgroups that warrant targeted attention. These findings can inform policy makers, programme managers, and civil society actors in designing targeted policies and interventions for migrant subgroups at an increased risk of poor sexual health, such as middle-aged and elderly migrants, the least educated, and those who do not fully conform to social expectations on gender identity/sexual orientation. To improve sexual and reproductive health outcomes, it is essential to identify and address the barriers that hinder migrants’ access to relevant health services.

Following the #MeToo movement and a Facebook campaign known as #Nödvärn (selfdefense), sexual and gender-based harassment in the context of Swedish police work has received increased attention. This study aimed to investigate the occurrence of sexual and gender-based harassment, the common types of harassment, and the organizational factors that officers perceive to be enabling the occurrence of such harassment. The current study employed a mixed methods explanatory sequential design. The quantitative phase involved 151 police officers to assess the prevalence and the more common types of sexual and gender-based harassment. The qualitative study, with a focus group and 12 individual interviews with police officers, aimed to explain the quantitative findings and explore how officers perceived such harassment and the enabling organizational factors in police work. The results showed that female officers reported significantly higher gender-based harassment than male officers. However, there was no significant gender difference in sexual harassment, and male officers also reported a high occurrence of sexual harassment from their colleagues and supervisors, who were mainly men. Verbal sexual harassment was reported as the more common type of harassment. The findings showed a prevailing toxic jargon among officers in the police work environment. Moreover, they stated a degree of silence against such harassment that makes identifying and addressing the problem complicated. Furthermore, there is a lack of skills and competence among police managers regarding handling such harassment. The findings underscore the need for ongoing organizational efforts to tackle cultural and managerial issues within the police organization.

Background: Decentralization has been a prominent strategy to enhance health systems’ efficiency, service quality, autonomy and accountability in low- and middle-income countries (LMICs) like Tanzania since the 1990s. Previous studies have mainly focused on assessing how much power for decision-making on different health system functional areas is granted to local-level authorities from the central government and the interconnections between decision space, organizational capacity, and accountability mechanisms. Empirical evidence on its impact on performance remains limited. This study investigates conditions for good performance in a decentralised health system of Tanzania.

Methods: We used fuzzy set qualitative comparative analysis to analyse the necessary and sufficient conditions for good health system performance. Eighteen purposively districts were chosen to capture variations in performance and geography in a multiple case study approach.

Results: Functional Health Facility Governing Committees (HFGCs) emerged as a necessary condition for good performance. To achieve good performance, however, there is a need for functional decision space among managers or high accountability among managers or high capacity of staff/ okay level of staffing.

Conclusion: The study underscores the importance of the interplay between decision space, organizational capacity, and accountability in improving health system performance. While decentralization aims to provide greater autonomy, effective implementation depends on the development of local capacities and oversight through accountability. Decentralization alone is not sufficient to enhance healthcare delivery; HFGCs and their local context that promote (social) accountability are essential. Further research is warranted to identify interventions supporting HFGCs in fulfilling their mandates and enhancing health service delivery.

Background: This scoping review identifies strategies potentially addressing the ‘workforce crisis’ in rural social care. The increasing global demand for social care has been coupled with widely recognised challenges in recruiting and retaining sufficient staff to provide this care. While the social care workforce crisis is a global phenomenon, it is particularly acute in rural areas.

Methods: The review identified 75 papers which (i) had been published since 2017, (ii) were peer reviewed, (iii) concerned social care, (iv) were relevant to rural settings, (v) referenced workforce shortages, and (vi) made recommendations for ways to address those shortages. Thematic synthesis was used to derive three analytical themes with a combined 17 sub-themes applying to recommended strategies and evidence supporting those strategies.

Results: The most common strategies for addressing social care workforce shortages were to improve recruitment and retention (‘recruit and retain’) processes without materially changing the workforce composition or service models. Further strategies involved ‘revitalising’ the social care workforce through redeploying existing staff or identifying new sources of labour. A small number of strategies involved ‘re-thinking’ social care service models more fundamentally. Very few papers specifically considered how these strategies might apply to rural contexts, and evidence for the effectiveness of strategies was sparse.

Conclusion: The review identifies a significant gap in the literature in relation to workforce innovation and placed-based studies in rural social care systems. It is unlikely that the social care workforce crisis can be addressed through continuing attempts to recruit and retain workers within existing service models.