Capacity Development for Healthcare Systems in Low- and Middle-Income Countries. Assessing the effectiveness of an advanced international training programme in sexual and reproductive health and rights in Africa and Asia

Sammanfattning: Background: The 2030 agenda for sustainable development calls upon all nations to make critical investments in their health systems to deliver universal access to Sexual and Reproductive Health and Rights (SRHR). Capacity development is listed among the strategies for achieving sustainable development goals. Although capacity development has been a major component of international development for decades, its effectiveness has limited evidence. This thesis aims at evaluating the effectiveness of an International Training Programme (ITP) in sexual and reproductive health and rights (SRHR) and to understand the role of different actors and contextual factors in capacity development for health systems in low-and middle-income countries. Religion and culture were hypothesised to be significant determinants for changing healthcare practitioners’ SRHR attitudes and practices. Methods: The study population was healthcare practitioners (HCPs) enrolled in the ITP from 13 countries in Africa and Asia. In study I, in-depth interviews with 28 HCPs were conducted and analysed using qualitative content analysis. Studies II and III were based on quantitative data from a sample of 115 healthcare practitioners and analysis was done using multivariate linear regression. Study IV utilised data from an instrument designed for evaluating the ITP change projects. Data analysis was done using logistic regression and 99 change projects were included in the final analysis.Results: Findings from study I indicate that local context, personal values, and social norms influence healthcare practitioners’ SRHR attitudes and practices. In study II, high level of self-rated SRHR knowledge, normative SRHR attitudes and active knowledge seeking behaviour were significant predictors of normative SRHR practices before the ITP intervention. Study III indicates that the ITP intervention was effective in improving the participants’ SRHR knowledge, attitudes, knowledge seeking behaviour and SRHR practices. Improvement in active knowledge seeking behaviour was a significant predictor of changing SRHR practices. Study IV, indicates that improved team capacity resulted in significant improvement in organisational effectiveness and support from partner organisations increased awareness of and demand for SRHR services. Conclusion: The findings suggest that the ITP approach for improving the capacity of healthcare practitioners (as change agents) was associated with improved organisational effectiveness. Other factors that positively contributed to organizational effectiveness were support from partner organizations and involvement of the media. Support from partner organization was also critical in increasing access to, and demand for, SRHR services. The use of new SRHR approaches seemed to negatively influence the effectiveness of organizations. Additionally, the findings suggest that although healthcare practitioners understand the importance of rights in SRH, they did not conform to the principle that rights apply to all components of SRHR and all persons in all settings. Howver, contrary to the evaluation hypothesis, religion and culture did not have a significant influence on changing SRHR practices. Instead, it was the improvements in participants’ knowledge seeking behavior that significantly predicted positive changes in SRHR practices at the end of the intervention.These findings highlight the potential of training interventions in contributing to the capacity development of healthcare systems in low-and middle-income countries.