Practice of Leadership, Governance, and Management Related to Maternal Nutrition Intervention Research Embedded in Antenatal Care in Burkina Faso

ABSTRACT.

Maternal nutrition intervention research (MNIR) embedded in antenatal care (ANC) was conducted in Burkina Faso to improve reproductive services. The aim of this study was to understand and document the contributions of leadership and management at various health system levels in improving resource management and maternal nutrition service coverage. It was a qualitative case study conducted from July to December 2022 with 44 participants from the Boucle du Mouhoun and Hauts-Bassins health regions. It consisted of interviews with key managers and document reviews. This study demonstrated that strengthening maternal nutrition through ANC in Burkina Faso was feasible and significantly impacted nutrition practices within a year. Coordination involved national and regional actors, nongovernmental organizations, and the private sector, ensuring effective collaboration. Leadership was shared with the private sector, but not effectively at the central level. Inputs and databases were managed by the private executive association and were not integrated into the National Health Information System. The health system’s usual organization was respected, with well-defined roles and effective communication, despite some delays in per diem payments and a lack of implementation tools. Monitoring and follow-up were systematic, involving quarterly and monthly review meetings. The project showed significant improvements in maternal nutrition knowledge, weight gain, ANC visits, anemia management, and early breastfeeding initiation, despite minimal changes in self-efficacy, beliefs, and family support. The MNIR was successfully implemented in four health districts, with private sector involvement improving communication and leadership. The project enhanced the health system’s resilience against terrorism and coronavirus disease 2019, demonstrating potential for expansion to national implementation.

INTRODUCTION

Despite several efforts in Burkina Faso, the maternal mortality ratio stagnated at more than 222.9 deaths per 100,000 live births in 2019, and neonatal, infant, and child mortality rates remain high at 23, 43, and 82 deaths per 1,000 live births, respectively.^1–3 This led to a search for the causes of this underperformance, including factors related to health system governance.

Governance is defined as the provision of policy direction to the entire health system, the coordination of actors, and the regulation of the different functions, levels, and actors of the system. It ensures the optimal allocation of resources and the maintenance of accountability to all stakeholders, with authority exercised among several governmental and nongovernmental actors for collective decisions made and implemented.^4,5 In the health field, the term is sometimes used as a synonym for “executive function,” especially when the term or its translation is problematic.⁶ Indeed, the stewardship function of the health system sometimes refers to the ability to formulate strategic direction, ensure effective regulation and the availability of tools for implementation, and provide the necessary usable information on health system performance to ensure accountability and transparency.⁷ Thus, the concept of governance is inextricably linked to that of performance, which relies on effective leadership. Leadership is the ability of a person to influence, motivate, and enable others to contribute to the effectiveness and success of the organization.⁸

There have been studies of governance and leadership in Burkina Faso, but they have focused on the health information system (HIS), the implementation of universal health coverage, and the day-to-day governance of health facilities.^9–11 None of them specifically address the issue of governance and leadership in the field of maternal health and nutrition. In the study conducted by Sombié et al.,¹² it was demonstrated that numerous interventions and strategies have frequently been used to address the barriers contributing to the second (patient transfer) and third (within health facilities) delays in reducing maternal mortality. However, there is a clear need to enhance the implementation process through effective monitoring and evaluation systems, as well as to develop localized solutions at the community, district, regional, and national levels to improve the execution of control strategies and interventions. Specifically for health districts (HDs), although management quality is important, leadership and vision are essential for improving access to care in an integrated health system.¹³ This requires leadership and management skills and practices within the framework of governance for maternal and child health. Overall, policymakers need to ensure that the performance measurement approach as a whole is an integral part of governance systems.¹⁴ In the present study, the governance and leadership approaches used by HDs and peripheral health centers (PHCs) in Burkina Faso during and after the maternal nutrition intervention research (MNIR) were examined.

MATERIALS AND METHODS

Study setting.

This study covered two health regions (Hauts-Bassins and Boucle du Mouhoun), which were the focus of the MNIR in Burkina Faso. The intervention was implemented in forty health facilities across four HDs in both regions. Between 2019 and 2020, the Ministry of Health and Public Hygiene worked with its partners to create and execute a plan to enhance maternal nutrition components through antenatal care (ANC) services. They also explored integrating these components into ANC in the Boucle du Mouhoun and Hauts-Bassins regions. An important aspect was using the existing ANC platform and strengthening various components of the health system to ensure effective service delivery and improved health and nutrition outcomes. The study setting is presented in Supplemental Table 1, showing the PHCs selected by HD and health region, as well as those planned for interview and those interviewed.

Study design and period.

This case study was conducted from July to December 2022 and is based on a qualitative approach. It involved in-depth interviews (IDIs) with key managers at various levels of the health system, including the national, regional, district, and facility levels. Selected primary health centers (PHCs) at the district level were also included in the study.

The PHC is a primary health (healthcare) center (PHC), which serves as the basic structural and functional unit of public health services in developing countries. Each PHC is managed by the Health Center Management Committee (HCMC) and promotes greater access to health care by providing essential generic drugs (EGDs), applying the principle of self-financing for the health center. The PHC is supervised by the Health District Management Team (HDMT).

Target population and study sample.

The main actors who fully or partially participated in the implementation of maternal nutrition at each level of the health system directly involved in the MNIR were interviewed as follows:

• ‐At the regional level: both management teams (board of direction) of Hauts-Bassins and Boucle du Mouhoun;
• ‐At the district level: all four HDs of Boucle du Mouhoun (Boromo and Toma HDs) and Hauts-Bassins (Dandé and Lena HDs);
• ‐At the health facility level: four of the twenty PHCs per health district during the MNIR.

Because of the security situation in Burkina Faso, there have been changes in the PHCs in the Toma Dande HDs (Supplemental Table 1). Specifically, the Niempourou PHC was replaced by the underperforming second PHC (Saran) in the Toma HD. Additionally, the PHC of Banwaly was replaced by the underperforming second PHC (Sangoulema) in the Dande HD. Lastly, the Kokoroba PHC was replaced by the high-performing second PHC (Samandeni) in the Dande HD.

If the staff moved, the researcher tracked and negotiated with them for an IDI. Otherwise, their deputy or assistant, who participated in the MNIR, replaced them.

Data collection.

Regarding the study variables, data have been collected on aspects related to the leadership and management model of Management Sciences for Health, integrated with the WHO pillars of the health system and the model from van Olmen et al.^4,15,16 We sought activities related to leadership and management that have taken the form of training, orientation meetings, supervision, coaching, planning meetings, coordination, and progress reviews or reports.

For this, we used 1) the interview guide during the face-to-face individual IDIs and 2) data collection to analyze project implementation documents.

The tools addressed the following themes related to attributes and practices at the intermediate and peripheral levels of the health system: 1) leadership, management, and governance in the regions and districts; 2) role and participation in governance and management teams, as well as the governance and management mechanisms adopted during the intervention by the health centers; 3) support for management during the intervention; 4) monitoring processes; 5) reinforcement of governance and management teams and mechanisms during the intervention by the health centers; 6) iron and folic acid (IFA) supply chain and stock management; 7) factors improving the situation of maternal data utilization; 8) planning and implementation documents; 9) objectives known and shared during the frameworks (ownership process); 10) management of structure and documentation; and 11) review of the existing situation and use of implementation documents (including a review of meeting notes, memos, health information, and reports).

Two trained interviewers, specialized nurses with experience in health system research in Burkina Faso, were selected for the study. Each nurse conducted the study in one health region.

STATISTICAL ANALYSES

Using the themes described in the “Data collection” section, the data was transcribed, analyzed, and triangulated with document reviews, using a deductive thematic analysis. NVivo (version 12) qualitative data analysis software (Lumivero, Burlington, MA) was helpful for the data analysis. Saturation of data was reached; however, we continued to interview the entire sample population as planned. The final analysis was contextualized with the empirical and theoretical literature.

RESULTS

A total of 46 participants were interviewed out of the 60 planned for the two health regions, four HDs, and eight PHCs (Supplemental Table 2).

The survey was enhanced by interviewing the leaders of ANC at the Direction of Family Health and the Direction of Nutrition at the central level of the Ministry of Health and Public Hygiene.

Project planning and collaboration with partners during and after the project.

Maternal nutrition intervention research: starting point of the project, consultation framework for implementation, and role of actors.

According to central-level actors, the project aligns with the priorities of the Ministry of Health and Public Hygiene. It follows the WHO recommendations on maternal nutrition, prenatal care, and breastfeeding programs for newborns and young children (BNYC) up to 2 years old. The aim was to improve maternal nutrition through prenatal care. The project received participation; however, an actor from the central health system mentioned some shortcomings: “We believe that there were shortcomings in the development of the project and especially in communication during the project….” Considering the current leadership structure of the project, known as the Directorate of Family Health, it appeared that some respondents directly involved in the project were not fully knowledgeable about certain aspects. They mentioned delegating tasks to follow up on answers. This was confirmed by a participant at the central level who stated that “We were in charge of advocacy… for the aspects of implementation and follow-up, the focal point will be able to give you the details.”

“At the regional level, some individuals mentioned their participation in central-level activities. They participated in the validation meeting of the ANC register, considering the WHO-recommended eight contacts. One regional participant stated that…”: “…the collaboration is effective and is expressed through the training of actors, joint supervision and data validation meetings; the roles of the actors are known at each level by the HRD [Health Regional Direction] agents, and coordination is ensured by the Regional Director of Health.” However, the agents at the regional level were not aware of the initial idea and did not participate in validating the basic documents because they were concerned that these were provided by external partners. One participant mentioned that “…they were just informed that the region was involved in the project.” For some of them, it is “…NGOs [nongovernmental organizations] who came up with the idea.” For others, “…the activities are the responsibility of the system and partners wanted to support by facilitating things, the different surveys baseline, the testing of the communication tools, and the training of the actors for the implementation.”

At the HD level, the actors mentioned the activities at the beginning of the project. According to one respondent, there was “…the advocacy workshop, the intervention package validated and supported, the implementation process, and the roles of the different actors shared and known.”

According to actors from the PHCs, the starting point was the information from the HDMT. One participant stated that “…the roles were known: the HDMT for coordination, the PHCs [primary health centers] and the CBHWs [community-based health workers] for implementation, and the BAFW [the nongovernmental organization named the Burkinabe Association for Family Welfare] for accompaniment.” In detailing the role of the PHCs, the following aspects were mentioned: supervision, monitoring, training of community-based health workers (CBHWs), participation in meetings at the HD level, and monthly meetings with CBHWs.

The chairs of the PHC management committee stated that they were not involved in the initial idea but were involved in the launch. Their roles included participating in advocacy meetings, creating signs to identify the PHC and service points, making curtains for doors and windows, purchasing beds, maintaining the premises for an inviting setting, selecting role models, conducting information sessions for cotton producer groups and village women, organizing awareness-raising activities for the population about the PHC’s activities, including the locations and dates of meetings, conducting awareness-raising activities for women and their husbands, and coordinating activities by exchanging ideas with the Head Nurse to find solutions and holding meetings of the PHC management committee.

The CBHWs stated that they were not involved in the initial idea but participated in review sessions at the PHC. Upon their return from the HD, they were informed by the head nurse that their PHC had been identified by the HDMT. Their main roles included conducting sessions on “Groups for Learning and Monitoring Optimal Infant and Young Child Feeding Practices” (GLMOIYCFs; known as GASPA in French) for pregnant and lactating women, raising awareness among husbands and mothers-in-law, holding monthly meetings with leaders, engaging in discussions with leaders, submitting monthly activity reports, and participating in monthly PHC meetings. To perform these activities, the CBHWs required coordination among themselves. One CBHW mentioned that “…Between us 2 CBHWs in my village, we gather to prepare the activities at village level, then we inform the women involved….”

Integration of MNIR in HD planning.

The integration of MNIR in HD planning was completed during the project’s development phase after analyzing the situation and health region priorities. “These activities are identified in relation to the implementation strategies of the action plan,” stated one participant from the regional level. Another participant at the regional level noted that “… from the beginning of the project, the HDs involved have taken into account MN [maternal nutrition] in their AP [action plan].” This is confirmed by participants from the HDs. One participant stated that these activities had occurred “…since the action plan.” Another participant declared that “…it is integrated into the PMA [minimum package of activities] and into the AP [annual action plan].”

Arrangements for health centers to continue maternal nutrition activities after project completion.

To continue the project activities, healthcare professionals were instructed to implement the activities in the health centers. One participant from the regional level stated that “…they were instructed to integrate the project’s achievements into their routine by taking ownership of them.” Another participant from the regional level added that “…impressed by the results achieved in such a short time, we instructed the HDMTs [heads of the health district management teams] to integrate the MN [maternal nutrition].” Additionally, an actor at the HD level noted that it is a question of “integrating training modules in the general training courses on management of malnutrition, EONC [emergency obstetric and neonatal care].” Another participant mentioned the need to “…capacitate people, implement mentoring or tutoring, and on-site training.”

A summary of the results from the documents and aspects related to the project identified by the surveyed HD is presented in Table 1.

Table 1.

Summary of the results of the documents and aspects related to the project found by the health district surveyed

N°	Documents	Health Districts				Level Achieved
		Boromo	Dande	Lena	Toma
1.	Partners and health regional direction partnership agreement: the existence of a signed agreement	No	No	No	No	0.0%
2.	Annual action plan 2021 of the regional health direction: situational analysis by strategic area or orientation, operational planning capitalizing lessons learned from activities implemented	Yes	Yes	Yes	Yes	100.0%
3.	Pool of regional trainers (list of trainers trained)	Yes	Yes	Yes	Yes	100.0%
4.	Guidelines and technical advice:	6	5	6	6	96.0%
	a) Training the trainer modules	Yes	Yes	Yes	Yes	100.0%
	b) Healthcare provider training modules	Yes	Yes	Yes	Yes	100.0%
	c) Community-based health worker training modules	Yes	Yes	Yes	Yes	100.0%
	d) New recommendations on antenatal care and maternal nutrition interventions	Yes	Yes	Yes	Yes	100.0%
	e) Maternal nutrition intervention kit	Yes	No	Yes	Yes	75.0%
	f) Communication materials (picture box, posters, tip cards, flyers, etc.)	Yes	Yes	Yes	Yes	100.0%
5.	Minutes of senior staff meetings: agenda, resolutions and recommendations made for maternal nutrition, implementation progress	Yes	Yes	Yes	Yes	100.0%
6.	Executive Board minutes: agenda, resolutions and recommendations for maternal nutrition, implementation progress	No	No	No	No	0.0%
7.	Minutes of regular and special between “Partners, health regional Direction, and Burkinabe Association for Family Welfare (BAFW) the organization in charge of the implementation” meetings: agenda, actions taken at the beginning of the project, at mid-term, during crisis meetings, and at the end of the project	Yes	No	Yes	Yes	75.0%
8.	Minutes of the regional Technical Committee on Health (meeting regrouping only health agents from public and private sectors at the health regional level): semi-annual meetings	Yes	Yes	Yes	Yes	100.0%
9.	Minutes of the regional technical committee on health and nutrition (meeting regrouping all actors about health and nutrition in the health regional level): semi-annual meetings	Yes	Yes	Yes	Yes	100.0%
10.	Report from the regional monitoring committee of the national health development plan semi-annual meetings	Yes	No	Yes	Yes	100.0%
11.	Inventory reports from the district’s distributing depot for monitoring iron–folic acid and sulfadoxine–pyrimethamine stock: stockouts, actions taken	Yes	Yes	Yes	Yes	100.0%

Participation in the different stages of the project.

The actors at the regional level reported that they were involved in early project activities. One respondent noted “…their involvement in the launch of the project, advocacy and sensitization during implementation. We also note the involvement of the Center management committee [the primary health center management committee] at the level of the health facilities.” He added that “this facilitated the functioning of the project and created enthusiasm around the objectives of the project, showed the involvement of the population, participation in the quarterly review meetings in the health districts, participation in the supervision in the districts, involvement of the CBHWs and the Center management committee [the primary health center management committee].” At the regional level, one respondent reported their participation in the following activities: “…research, training, pre-testing and validation of communication tools such as the weight gain monitoring form.…The CBHWs also took part in this study and even during the community meetings [the semi-annual community meetings at the primary health center level].” Another respondent mentioned the following activities: “…fluid planning and coordination, supervision, monitoring and data use….”

According to the actors in the HDs, the project took into account the actors in the field during the survey, the monitoring of indicators, and the opinions of the beneficiaries. According to a respondent at the district level, participation included “…the survey before the implementation of the project, the involvement of the community, the validation of the evaluation tools, the quarterly monitoring of the providers and CBHWs which allowed for the correction of shortcomings as they arose, the review meetings which allowed for the sharing of experiences between the HNs [head nurses of the primary health centers] and the maternity managers.” Another respondent at the district level stated that “…the presentation of the initial indicators, the involvement of women at the IFPM [infant and young child feeding practice learning and monitoring groups; in French, GASPA] level, and the opinion of the beneficiaries being sought.”

During the project, the PHCs participated in various activities, including the project launch, supervision, monitoring, training of CBHWs, review meetings, monthly meetings with CBHWs, and providing services related to ANC. Additionally, they conducted awareness-raising activities on taking IFA, exclusive breastfeeding, food diversity, and early breastfeeding.

Regarding the population, the actors from the PHCs mentioned that they were engaged in awareness-raising activities and information meetings. This included the participation of leaders such as customary and religious leaders, Village Development Committees (VDCs), as well as the involvement of women, their husbands, and mothers-in-law.

To fulfill their role, the CBHWs reported that they received training on the following topics: promoting dietary diversity using local foods, continuing to take IFA supplements for up to 42 days after childbirth, involving husbands and mothers-in-law, conducting home visits to encourage and reinforce healthy practices, identifying local foods to promote dietary diversity, conducting awareness-raising activities, organizing community-level ANC sessions, promoting early treatment of illnesses, encouraging early breastfeeding, and understanding the relationship with the weight gain curve.

Structure organization.

Roles and responsibilities.

According to the actors, at the regional level, the Heads of Services are appointed on the basis of the proposal of the Regional Director of Health. The office managers and deputy heads of office or services at the regional level are appointed by the decision of the Regional Director upon the proposal of the heads of services. Additionally, each head of service and head of office receives their mission letter. If the Regional Director and a head of service are absent, an interim memorandum is drafted to assign the proceedings to an interim, who produces a report at the end of the term to update the incumbent. For example, one participant said that “… The RHD [Regional Health Director] proposes the head of services to the MoHPH [Ministry of Health and Public Hygiene] via the SG [Secretary General]…. The interim is not fixed, and there are supports available to him.”

At the HD level, the HDMT and each member of this team play a role in managing appointments and regulations within the team. According to one participant, “…the staff is chaired by the HDMT with three-quarters of the team.… The DMT [District Management Team] members are appointed by the RHD on the proposal of the HDMT.… There are rules of procedure for the DMT and the mission letters.” According to another respondent, “…it is necessary to take into account the notion of the most senior doctor, the job description, and the people who are considered dynamic and professional.”

Functional bodies for consultation and decision-making at the regional and HD levels.

The actors at the regional level mentioned the consultation frameworks in place. The details of these consultation frameworks were provided by a respondent from a regional health direction, stating “…the usual consultation bodies are: weekly staff meetings, the BD [board of directors], the RHNC [Regional Health and Nutrition Committee], the DHC [District Health Councils], weekly planning meetings, and the quarterly meetings between the Heads of the PHCs and the DMT.”

For the actors in the HDs, they cited various consultation bodies and channels. Different respondents mentioned different bodies, some of which overlapped. For example, one respondent cited “The DMT meeting, the weekly staff meetings, the quarterly meetings between the Heads of the PHCs [primary health centers] and the DMT, the meetings between the Heads of the PHCs [primary health centers], the DMT and the maternity managers, focal point meetings, Whatsap groups.”

For the PHC actors, the bodies and channels of consultation at the local level included the monthly meetings of the Management Committee of the PHC, the biannual PHC general assemblies, and the monthly staff meetings. Some of the Management Committee presidents of the PHCs added other elements, such as information dissemination in places of worship and advocacy to the cotton producers’ groups.

In the management and decision-making committees and bodies, topics such as the implementation of mass campaigns, the monitoring of indicators of the Expanded Program on Immunization (EPI), the situation of debts related to medical drugs, the monitoring of nutrition indicators, and the evaluation of screening campaigns for acute malnutrition were discussed. At the level of the RHD, a participant stated that “…all the programs, especially maternal nutrition, were presented.” According to a participant from the HD, the discussion focused on “…the status of the IFA, the evolution of the ANC indicators, the intake of IFA,” and another participant mentioned “the nutrition indicators.”

Regarding the follow-up of the project, decisions and recommendationswere made either in isolation or integrated into the execution of other activities. In this context, a respondent at the regional level stated “…the monitoring is done specifically during the quarterly joint supervision [Regional Health Direction and partners] visits to the health districts…. It is also done during the biannual integrated supervision of the health districts by the RHD [Regional Health Direction].” According to another respondent from the HD level, “…the follow-up is achieved by holding the quarterly review meetings in each health district with the participation of the RHD, and conducting the joint supervision of field actors [Direction of Family Health, Direction of Nutrition, Regional Health Direction, and partners], using tools such as the supervision grid, the CBHW report template and the HSPC [Health and Social Promotion Center, or primary health center] report template.”

For actors at the HD level, there are plans and tools for monitoring. Typical of their response was one person who stated that “…the plan for implementing the recommendations is done and evaluated.” Another stated that “…the progress report and the decentralized data entry allows for an analysis and a quarterly evaluation of the indicators.” At the PHC level, the following tools were cited: monthly report form, PHC level data collection book, CBHW monitoring chart, ANC register with eight contacts, Weekly Telegram Official Letter form, awareness tools (flyer, poster, awareness box), and CBHW tools. The PHCs have taken initiatives by implementing tools developed through the creation of a meeting book template for PHC head nurses and CBHWs.

During the follow-up, positive aspects were noted, such as the effective implementation of the recommendations resulting from the supervision and evaluation meetings by the field actors, the strong involvement of health agents at all levels, community adherence, an increase in the number of early ANC visits (in the first trimester of pregnancy), and the availability of reporting and awareness tools. Regarding monitoring, the PHCs identified the following positive points: monitoring as an opportunity to share experiences, increased awareness of the use of ANC services, improvements in indicators, a decrease in the number of anemia cases, and the effectiveness of supplementation and counseling on long life insecticide-treated nets.

Among the project’s points for improvement, the lack of community support and delays in payment were mentioned as demotivating factors for CBHWs and head nurses of PHCs. This was highlighted by the following comment from one participant at the PHC level: “Despite the efforts made, we have noticed a low level of support from the population. We do not know why, even though there were a lot of sensitization sessions, there was also insufficient motivation on the part of the CBHWs….”

Project implementation, monitoring, and evaluation.

Implementation and monitoring of the execution of recommendations.

The follow-up took place during joint or integrated supervision visits. According to one participant, there is “…a good involvement of the hierarchy through responses to requests and support for problem-solving and participation in periodic meetings.” Another participant noted that “…the legal frameworks allow for the follow-up of the execution of recommendations.”

At the operational level, the monitoring of the execution of recommendations was conducted through the following statements: “…the implementation plan of the recommendations is done and evaluated,” according to one participant, and “…during supervision and specific coaching,” according to another participant.

The HDs surveyed conducted supervisions to strengthen the skills of health providers and CBHWs in maternal nutrition interventions. The supervision reports frequently focused on themes such as project implementation, evaluation of previous recommendations, availability and use of communication tools, data collection support, equipment functionality, prenatal care, home visits, educational talks by CBHWs, analysis of reported data, and the capacity of providers to analyze collected data. According to the PHCs, the inputs used in the project included drugs (IFA, sulfadoxine–pyrimethamine (SP), and deworming drugs) and equipment (mainly bathroom scales for pregnant women). The input supply cycle consisted of drug orders from the district dispatching depot and equipment allocations for the PHCs. The techniques used to manage inputs included inventory based on orders, receipts, disbursements, and balances. The techniques and tools used to control input management at the district level were stock cards, purchase orders, and notebooks and inventory cards. To avoid stock-outs, workarounds were implemented, including transfers from neighboring PHCs and emergency orders.

There was a baseline evaluation (baseline survey)¹⁷ and a final evaluation (final survey)¹⁸ of the project. The districts interviewed participated in the different phases of the project evaluation (baseline and final). The essential baseline and final survey indicators of the MNIR are presented in Supplemental Table 3.

Collaboration, process, and success aspects of the project.

At the central level, it was found that there was good cooperation in the project. In addition, the Direction of Family Health viewed itself as the leader of the project and invited the Direction of Nutrition to participate. According to exchanges with actors at the central level, there was a lack of shared governance of the project; one of the technical directions (Direction of Nutrition) felt that it was being asked to participate. From the central level, one participant identified the “leading” structure and its role: “The DFH [Direction of Family Health] had the leadership of the project at the Ministry of Health level…. It was from the DFH that the information was sent to the other structures.” This could reflect what is perceived as unshared leadership, as indicated by a respondent’s words: “…we are just invited to the activities, …we are confronted with the facts….” Regarding the activities, there were mainly supervision sessions, training sessions, and consultation committees.

The actors were unanimous in highlighting the added value of the project in terms of staff capacity building, maternal nutrition, and women’s empowerment. From this point of view, one participant stated that “…given what the project has brought to the health districts, we have suggested scaling up the project in the two regions”; and another stated that “…we intend to disseminate the project’s achievements in the two RHD [Regional Health Direction] to mobilize and scale up….” During the discussions, dissemination was limited to the institutional level, and there was no other structure for dissemination beyond the return of the project results to the actors involved in the project.

For actors at the regional level, the success of the project can be attributed to several key factors, including the existence of a contract between the RHD and Aliva and Thrive, the appointment of a project focal point at the regional level, joint planning of activities, the involvement of the RHD in selecting a regional champion for exclusive breastfeeding, community sensitization, and the population’s adherence to the project. This is reflected in the following statement by a respondent: “A success due to the frank collaboration with the presence of NGOs [nongovernmental organization] actors at the RHD [Regional Health Direction], and the facilitation of the implementation.” A participant noted the positive role of the RHD: “…the RHD [Direction régionale de la santé] has played a role in facilitating the implementation of the activities in the field, participating in the supervision of the RHD towards the agents at the level of the health districts, accompanying the actors in the implementation and participating in the follow-up of the project through the evaluation meetings.”

At the HD level, the Head of the District Management Team (DMT) emphasized the importance of good cooperation from beginning to end, particularly during participation in an advocacy workshop. This was evident in the words of one respondent, who said that “…there was the meeting to define the training modules. All of this facilitated the implementation.” Another respondent added that “…the collaboration is not new. There was the involvement of all the actors, the improvement of maternal and child health, and the performance of the management team. We noted the support at all levels, not only financial but also technical. The collaboration is good and there was the commitment of the first actors.”

At the PHC level, one participant stated that “…the collaboration was facilitated by the involvement of all (health districts, primary health centers, community-based health workers), the good communication, the support from the health district, the regional health direction through the supervision sessions, the coordination and implementation of resolutions (example the antennal care planned every working day), the use of coaches, the commitment of the actors, and the financial motivation.”

The lack of success was related to the failure to explain the delay in motivating and paying the head nurses and CBHWs toward the end of the project. Challenges were also mentioned, such as “…the short time frame of the project…. The biggest challenge, has there been a behavior change?” according to one respondent at the district. In addition, the quality management of inputs such as IFA was cited as a challenge. This led another district respondent to state that “One of the difficulties was the intake of IFA, the risk of IFA shortage.” However, the aspects that require improvement are mainly related to the duration of the project. One respondent stated that “…What did not work well was the duration of the project, only one year. And that did not allow us to measure the impact.”

Regarding the quality of ANC services, there were major improvements in process quality, particularly for intensified maternal nutrition interventions. According to all participants, there was an increase in the number of consultations at the first pregnancy contact, in the number of women using IFA because of its importance, in the reduction of anemia in pregnant women, in the reduction of preterm births, in the early detection and treatment of acute malnutrition in pregnant women, and in the systematization of early breastfeeding in the intervention area. However, stakeholders also noted the increased workload of PHC providers and CBHWs in the villages.

The aspects related to the success and failure of the project are listed in Supplemental Table 4.

Internal and external communication and feedback, interpersonal difficulties, and conflict management.

Weekly staff meetings are held with the heads of services around the Regional Health Director and the members of the DMT around the Head of the DMT. “These staffs follow weekly meetings within each department led by the Head of Department at the regional level…. But there are irregularities in the holding of staffs and other meetings,” according to a participant. “General assemblies are also held quarterly, bringing together all the agents of the RHD [Regional Health Direction],” stated another respondent. Additionally, another participant noted that “the creation and animation of separate WhatsApp groups between the Regional Director and the heads of services of the RHD [Regional Health Direction], between the Regional health director and the Head doctors of the region, between the pharmacists of the RHD, between members of the same service at the RHD.” One participant remarked that “…each time a member participates in an activity, he reports to the staff and the general assembly. Each head of service must meet periodically. …the management committee set up is working on the resolution.” A participant emphasized communication with the community by making the following statement: “In addition, the communication officer is the interface between the DMT and the community world. Also, the feedback is provided by the communication officer.”

The primary challenges were the lack of prompt payment for the motivational coaching provided by the Burkinabe Association for Family Welfare, the PHC head nurses, and the CBHWs. As a solution, a participant proposed “to use communication, exchanges, concertation’s… to improve the conditions of motivation of ASBC [community-based health worker]… to pay on time the motivation fees.”

To manage conflicts, there are several mechanisms in place. One participant stated that “When a conflict breaks out in a department, the head of the department listens to both parties and tries to mediate, failing which the Regional Director is called upon to resolve it. If it is between department heads, the Regional Director undertakes the resolution by listening to the parties and then they find a solution together in the best interest of the department.” Conflicts are also managed at the district level. One respondent noted that “…conflicts are managed at 2 levels: If of a personal nature, there is the meeting between the agent and the HDMT [Head of the District Management Team]; and if in a general way, it is in DMT meeting.” A participant emphasized that: “…. each HN [head nurse] manages at his level. The DMT may have to travel to support the resolution of certain conflicts.” A participant made the following recommendation: “…privilege the meetings of the parties, the determination of the causes of the conflict and the proposal of a solution with a follow-up….”

Assessment of the level of involvement of the hierarchy (Regional Health Directors and their deputies and Heads of the DMT) and input management.

According to one respondent, there was “…a good involvement of the hierarchy through responses to requests, support for problem-solving and participation in periodic meetings….” The same respondent added that “The tools made available within the framework of the project were the procedures manual, the supervision grid, and the awareness-raising materials.” Additionally, the “ANC register was cited as a tool, taking into account the 8 contacts,” according to another participant.

The assessment of the level of involvement of the hierarchy (Regional Health Directors and their deputies and Heads of the DMT) in the implementation of activities during the project was viewed positively by the actors from the PHCs. In this regard, one participant stated that “…all the heads of the DMT and the RHD [Regional Health Directors] are with us during the assessments through the quarterly meetings between the DMT and the Head nurses of the PHCs….”

The CBHWs indicated that they were supervised. One CBHW stated that “…we are supervised. During supervision, we are observed working, and then after the discussion, we are told what to do to correct….”

The inputs used in the project included drugs and materials. One participant cited that “…the drugs such as IFA, SP and materials such as measuring rods, tools for the scales of pregnant women, the sensitization kit with themes related to MN [maternal nutrition].”

The input orders were described as “…the medicines ordered from the health district from the central purchasing office for essential generic medicines) according to a requisition system, and the equipment through specific allocations,” according to one participant. The same respondent stated that “the techniques used for inputs management were the computerized system and the manual at the level of the health districts.”

Regarding the techniques used to manage inputs at the district level, one participant stated that “…there is a semi-annual control to the district dispatching depots of the health districts.” As for workarounds used to avoid stock-outs, one respondent mentioned that “…the redeployment of EGDs [essential generic drugs] between the health districts or between PHCs [primary health centers], exchanges with the central purchasing office for essential generic drugs, and the instructions for emergency orders….”

Organizational management, documentation, and summary of the project.

A summary of the results from the management documents found in the surveyd HD is presented in Supplemental Table 5.

Communication and feedback to district teams, as well as the identification of essential adjustments, were provided during consultative frameworks and periodic meetings, which included a presentation of the intervention indicators. According to a regional respondent, “…all the statutory frameworks were opportunities to provide feedback….” Another participant from the district level stated that “…the feedback was done during the statutory frameworks, where the orientations are given.” At the HD level, one respondent noted that “…the feedback was given during the quarterly meetings between the DMT and the Head nurses of the PHCs….”

The general assemblies and monthly staff meetings, as well as the Community Management Committee at each PHC level, the District Health Council at the district level, the Board of Directors, and the Regional Monitoring Committee at the regional level, served as channels of communication for the staff. Indeed, a participant at the HD level mentioned that “…the general assemblies, the awareness-raising activities, the animation of the Groups for learning and monitoring optimal infant and young child feeding practices, the approaching leaders during certain campaigns.”

Related to the dissemination and communication for interacting with the population, a participant at the regional level stated that these included “the use of local radios such as communiqués (written and broadcast), the use of town criers and the use of posters at the level of the PHCs.”

Community-based health workers received feedback at the district and PHC levels during monthly meetings with health workers at the PHC, as well as during the presentation of monitoring results to the population at the PHC level. Furthermore, the process for reporting to the community takes into account the following aspects: information in places of worship, information from the chief of the village and the manager of the VDC, and the use of loudspeakers and town criers.

Regarding the recommended solutions for addressing difficulties, conflicts, and challenges, it was suggested that “…the accountability of the actors on the expected results of the project… the commitment of the HDMTs [Heads of the District Management Teams] and especially the scaling up” are essential. Additionally, a participant at the district level mentioned the use of “the mission letters,” and another participant at the district level discussed the “integration of the maternal nutrition into RH [reproductive health], during the supervision sessions, GLMOIYCFs, and the monthly meetings at the village level.” In the PHCs, actors reported addressing interpersonal challenges and disagreements by listening to the parties objectively, understanding the situation, and resolving it with a focus on team cohesion. A major issue for the maternal nutrition project was the need to consider the security context (geographically limited access) and the presence of coronavirus disease 2019 (COVID-19).

Regarding the obstacles and difficulties, and seeking answers, the PHCs provided the following aspects to improve the indicators:

• Regarding early breastfeeding, there was a reinforcement of awareness-raising during deliveries;

• For the administration of IFA 42 days after delivery, there was awareness-raising among women and verification of iron levels during post-natal consultations;

• Because of the high workload in the context of insufficient staff, the reorganization of services was implemented;

• To address the discrepancy between the indicators and the data to be collected, the support for the monthly activity report was standardized through validation from the primary source of the data;

• For the PHCs with two CBHWs for very large villages, there were explanations and encouragements to address the delay in motivating them;

• To change the mentality regarding the fact that ANC begins at 3 months of pregnancy, there was awareness-raising about the need for 180 pills of IFA;

• For the abandonment of harmful practices (such as purging and force-feeding) and the promotion of exclusive breastfeeding, awareness-raising activities were conducted;

• For the involvement of husbands and mothers-in-law, awareness-raising activities were implemented;

• For the fieldwork that limits women’s participation in GLMOIYCFs, there have been some sensitization sessions to emphasize the advantages of participation, along with the organization of very short sessions;

• For the arrival of new people in the village, additional awareness-raising activities were conducted;

• For the persistence of rumors (e.g., “…if the woman takes the IFA, it prevents subsequent pregnancies and increases the number of Caesarean sections…”), the sources of the rumor were identified, and sensitization sessions were organized to address the issue.

In summary, the project’s leadership and management results during its execution are outlined in Supplemental Table 6. This intervention research demonstrated that strengthening the delivery and exposure to maternal nutrition interventions through ANC provided by the public health system in Burkina Faso was feasible and had a significant impact on selected nutrition practices, even after less than 1 year of implementation.

Organizational, institutional, and ownership arrangements made to support the effective implementation of activities.

A summary of the results of the management documents found by the surveyed HD, from the agenda-setting to the establishment of the project, is presented in Supplemental Table 7, showing the ownership arrangements for the project.

To continue the project activity, it was requested that organizational and institutional arrangements be made to support the effective implementation of activities in the health centers. Thus, a participant from the regional level stated that “instructions were given to the disease control service of the regional health direction for monitoring through the nutrition office and the HIESC [health information and epidemiological surveillance center].” According to another participant from the district level, “…all the indicators have been integrated into the synoptic table. They are also put in the mission letter. The Head nurses of the PHCs are invited to integrate the maternal nutrition components into the general assemblies.”

According to the collection tools and activity reports, project activities are ongoing, as evidenced by weekly and monthly data collection, as well as various collaborations through committees and meetings. For example, in the Dande HD, activities are outlined in the operational plan for 2021, and the Head Nurse of the PHC of Mana received his mission letter, which includes maternal nutrition indicators. In the Lena HD, the distribution status of EPI materials includes maternal nutrition inputs for 2022. Furthermore, the Boromo HD has added additional IFA pills to the initial stock for pregnant and lactating women to avoid shortages in the event of missed appointments. According to the collecting tools and activity reports, the project’s operations continue, as indicated by several examples of input management, such as the IFA (Supplemental Table 7).

DISCUSSION

The objective of this study was to better understand and document how governance, leadership, and management at the regional, district, and peripheral levels of the health system contributed to improved resource management and coverage of maternal nutrition services. Essentially, the project was managed primarily by administrative personnel. It was discovered that leadership was shared with the private executive sector during project implementation. However, this leadership did not appear to be shared at the central level of the Ministry of Health and Public Hygiene. The actors praised the project and expressed hope that it would be expanded to the regions that had implemented it, and even to the national level. The need to better manage human resources emerged to avoid work overload by appropriately assigning agents and adapting the organization of services.

The limitations of this type of study are methodological because of the cross-sectional design, which employs a qualitative approach and does not allow for statistical inferences or temporality. Additionally, the study design did not include a control area for comparison with the intervention, so not all changes noted in the areas can be attributed solely to the intervention, as other activities may have been occurring in the country that affected change. The population targeted in the present study primarily consisted of the HCMC, which served as a representative of both the population and the community leaders. A limitation of using the HCMC as a proxy for the population and community leaders is that it may not fully capture the diverse perspectives and experiences of the broader community, particularly those of marginalized or underrepresented groups.

Governance and leadership.

According to the WHO, one of the most challenging issues facing Member States is ensuring access to safe and effective health services for those in greatest need.¹⁹ To this end, as highlighted in this study, maternal nutrition is presented as a priority for reducing maternal and newborn deaths by implementing WHO guidelines through ANC.²⁰ This requires a vision and new approaches within the health system in Burkina Faso, supported by the Ministry of Health and Public Hygiene and its partners in this maternal nutrition project. This initiative is part of the governance of the Ministry of Health and Public Hygiene of Burkina Faso to address the specific needs of pregnant women. According to the WHO, ministries of health are responsible for leading health development and improving key health system functions, including leadership, governance, health care financing, service delivery, and resource creation for health development. Coordination efforts are made with other related ministries and departments.²¹

Leadership and governance are critical functions of health systems and require special attention.⁷ The health system leadership function involves developing strategic policy direction, ensuring effective regulation, obtaining usable information on health system performance, and organizing the health system to achieve the best health outcomes.²²

The practice of governance requires participation, accountability, subsidiarity, and transparency.²³ No issues of subsidiarity or accountability arose in this study, only questions about low or weak indicators. To legitimize the power of actors responsible for a decentralization policy, it is important to consider both formal and informal sources of their power. Nongovernmental actors are more influential at regional and local levels than at the national level.^24,25 In the present study, the intervention was not conducted in private healthcare facilities.

Governance involves the optimal allocation of resources and maintaining accountability to all stakeholders.⁴ Through the involvement of private, public, and community actors, the MNIR Project helped the Ministry of Health and Public Hygiene allocate resources for maternal nutrition through its partners. Thus, as advocated, governance involves the exercise of authority by multiple governmental and nongovernmental actors, the making and implementation of collective decisions, and collaborative stakeholder interactions.⁵ In the MNIR project, this collaboration was expected to occur without major issues. According to many authors, effective coordination and cooperation among stakeholders in the HIS are crucial for creating new collective capacities, strengthening professional skills, and maintaining an organizational climate that promotes individual and collective potential.^9,26,27 As stated by a participant regarding multi-level governance: “the coordination, the consultation, the cooperation and the communication between them [authorities] were essential for effective crisis management.”²⁸

Related to the MNIR, monitoring and supervision sessions were conducted, although their quality was not evaluated. This is important and requires the function of stewardship.⁷ Management tools are inadequate for managers to account for decisions and improve collective action regarding service quality, safety, and efficiency.²⁹ Governance is essential for designing, conducting, and evaluating collective action from an authoritative position. It is based on a management system, an information system, and a financing system, which ensure transparency, intelligibility, and incentives for professionals, managers, and the public.^30,31

Governance practices in healthcare institutions influence clinics on two levels: local governance, which structures action at the operator level, and overall governance, which represents the context in which operators function.³² This study suggests that governance is guided by support from the hierarchy, including regional health directors, DMT heads, PHC head nurses, management committees, and staff. As Ouattara¹¹ stated, “Being a member of the District management team and/or the management committee are all strategic positions.”

Leading the health system requires strong leadership. In this study, the leaders appeared more like managers. A leader is a person who directs, influences, and inspires others to achieve specific goals, distinguishing them from managers who can manage but not lead. In HDs, leadership and vision are crucial for improving access to care.^13,33 According to Desta et al.,³⁴ the district leadership development program helps improve district management capacity, structure, and practices, as well as the quality of care.³⁴

The Direction of Family Health and the Direction of Nutrition in Burkina Faso’s health system lack shared authority, a key component of leadership and governance. According to Hassel and Raveleau, true shared leadership occurs when each member feels accountable for the established goals and outcomes, promoting the best use of available skills.³⁵

Management of the health system and health project.

When managing the healthcare system, it is important to involve informed citizens in decision-making and in taking responsibility for their health.⁷ Leadership tasks within the system do not have to be handled solely by the central government or the Ministry of Health and Public Hygiene. Other entities, such as regional, district, and primary health center levels, can also play an active role in guiding the system’s function.

Health system managers improve health system performance by developing strategies and policies, gathering information, influencing partners, conducting advocacy, ensuring good governance, adapting to changing needs, and using legal, regulatory, and health policy instruments.⁷ The study demonstrates that “the system” connects strategic elements such as mission, vision, core values, focus areas, objectives, metrics, targets, and initiatives under the leadership of the Direction of Family Health, supported by the Direction of Nutrition, with a focus on continuous improvement activities and achieving desired performance levels.³⁶ The integration of a package of intensive maternal nutrition interventions into existing prenatal care services provided by public health facilities aligns with the latest world guidelines.³⁷

For this purpose, the following aspects advocated by Dehbi were taken into account in the maternal nutrition project: the identification of needs and priorities, the production of care and services, health financing, and general administration.²³ Everything started with the consideration of the project priorities, the global and national context, and the framework for its implementation. Additionally, the starting point was established at the central level with its partners. This means that strategic management, as described by Tucci, was considered, including continuous planning, monitoring, analysis, and evaluation of all the necessities an organization needs to achieve its goals and objectives.³⁶ Thus, Tucci suggested five steps in the strategic management process: 1) assessing the current strategic direction of the organization; 2) identifying and analyzing internal and external strengths and weaknesses; 3) formulating action plans; 4) executing the action plans; and 5) evaluating the extent to which the action plans were successful and making changes when the desired results are not achieved. This study found that aspects of the maternal nutrition project were included in the action plans of the operational structures, which were implemented, monitored, and assessed. The implementation of the project by the actors was therefore crucial for improving the indicators. In their study, Meda et al.¹³ showed that in low-resource countries, the management performance of district teams at the deconcentrated level can have a significant leverage effect on the health system. However, they added that leadership and vision will be critical to improving access and achieving rapid health impact and cost-effectiveness in an integrated health system.

The management team, including the district team, is responsible for managing health facilities by using skills in strategic problem-solving, human resource management, financial management, and operations.³⁸ This element facilitated the implementation of the maternal nutrition project in Burkina Faso, helping to avoid blockages and shortages of inputs through collaboration and communication, even if it was sometimes criticized. According to Meda et al.,³⁹ although all management functions are important, communication and decision-making are essential for effective HD management. Burkina Faso’s health system benefits from training in HD management for chief medical officers and, to a lesser extent, DMT nonmedical members, but not for head nurses in health facility management.

The debate in health system management revolves around managing adaptability versus efficiency, change versus stability, and centralized control versus decentralization and autonomy, as advocated by Chapman.⁴⁰ The maternal nutrition project was completed despite adapting to security challenges and COVID-19, suggesting a reorganization of services through the integration of resource management and skills management.

Management Sciences for Health emphasizes the importance of effective, efficient, and quality health services for organizational success, whereas Gomez-Mejia suggests that effective management performance roles are crucial for managerial success.^41,42 However, efficiency and effectiveness have become major considerations in the administration of social service programs and agencies, although efficiency is difficult to measure.⁴³ This was not the case in this study.

The study found that DMT capacity was significantly higher in high-performing districts, with health officials reporting greater teamwork, communication, and organizational commitment compared with low-performing districts.⁴⁴ Other study results also suggested a positive association between district-level management capacity and health system performance.^38,45–50

What is most important is the adherence of management according to the following three levels: 1) strategic managers (overall responsibility for the company), 2) tactical managers (responsible for implementing the directives of the strategic managers), and 3) operational managers (responsible for day-to-day supervision).³⁹ In their study, Sombié et al. have shown that several strategies, primarily aimed at removing barriers at the base of the second (transfer of patients) and third delays (within health facilities), have been implemented to reduce maternal mortality. However, there is a need to improve the implementation process with a robust monitoring and evaluation system and to identify solutions at the local (community), district, regional, and national levels to improve the implementation of control strategies and interventions.¹²

Population participation in the intervention.

The MNIR project aims to reduce malnutrition among pregnant women in the community, thereby decreasing maternal and neonatal morbidity and mortality. The project involves community participation, including representatives from PHCs and CBHWs, infant and young child feeding practice groups, local authorities, cotton growers’ committees, husbands, and mothers-in-law.

Empowerment, or social development, encourages active community participation in local public action, reducing inequalities and combatting exclusion, although it may not represent the ultimate level of community participation.⁵¹

Empowerment is crucial for project success as it improves population health.⁵² Indeed, according to Action Against Hunger, the five most frequently observed bottlenecks were 1) the lack of knowledge about the disease; 2) the lack of knowledge about the program; 3) the high opportunity costs; 4) the distance of the household or community from the service delivery site; and 5) previous rejection.⁵³ Therefore, it is important to involve the community early in the process, from the agenda and situation analysis to the assessment and reprogramming phases.

The WHO’s Health for All framework emphasizes the importance of horizontal approaches and health systems strengthening, involving all actors and obtaining strong leadership at local levels for optimal health outcomes.⁵⁴

CONCLUSION

The MNIR project, implemented by the Ministry of Health and Public Hygiene, successfully improved maternal nutrition in four HDs within the health regions of Boucle du Mouhoun and Hauts-Bassins. This article focuses on management and leadership practices during the implementation of the MNIR project. Conducted through collaborative private and public participation, this project successfully achieved its objectives, thereby improving the project indicators. Key successes include regular maternal nutrition offerings, community participation, communication, and shared leadership, showing how critical leadership and management are at different levels of the health system to enable better resource management for optimal coverage of maternal nutrition services and the achievement of goals.

Note: Supplemental materials appear at www.ajtmh.org.