Utilization of HIV and tuberculosis services by health care workers in Uganda: implications for occupational health policies and implementation

BACKGROUND

Access to HIV testing and subsequent care among health care workers (HCWs) form a critical component of TB infection control measures for HCWs. Challenges to and gaps in access to HIV services among HCWs may thus compromise TB infection control. This study assessed HCWs HIV and TB screening uptake and explored their preferences for provision of HIV and TB care.

METHODS

A cross-sectional mixed-methods study involving 499 HCWs and 8 focus group discussions was conducted in Mukono and Wakiso districts in Uganda between October 2010 and February 2011.

RESULTS

Overall, 5% of the HCWs reported a history of TB in the past five years. None reported routine screening for TB disease or infection, although 89% were willing to participate in a TB screening program, 77% at the workplace. By contrast, 95% had previously tested for HIV; 34% outside their workplace, and 27% self-tested. Nearly half (45%) would prefer to receive HIV care outside their workplace. Hypothetical willingness to disclose HIV positive status to supervisors was moderate (63%) compared to willingness to disclose to sexual partners (94%). Older workers were more willing to disclose to a supervisor (adjusted prevalence ratio [APR] = 1.51, CI = 1.16-1.95). Being female (APR = 0.78, CI = 0.68-0.91), and working in the private sector (APR = 0.81, CI = 0.65-1.00) were independent predictors of unwillingness to disclose a positive HIV status to a supervisor. HCWs preferred having integrated occupational services, versus stand-alone HIV care.

CONCLUSIONS

Discomfort with disclosure of HIV status to supervisors suggests that universal TB infection control measures that benefit all HCWs are more feasible than distinctions by HIVstatus, particularly for women, private sector, and younger HCWs. However, interventions to reduce stigma and ensuring confidentiality are also essential to ensure uptake of comprehensive HIV care including Isoniazid Preventive Therapy among HCWs.

How does capacity building of health managers work? A realist evaluation study protocol

INTRODUCTION

There has been a lot of attention on the role of human resource management interventions to improve delivery of health services in low- and middle-income countries. However, studies on this subject are few due to limited research on implementation of programmes and methodological difficulties in conducting experimental studies on human resource interventions. The authors present the protocol of an evaluation of a district-level capacity-building intervention to identify the determinants of performance of health workers in managerial positions and to understand how changes (if any) are brought about.

METHODS AND ANALYSIS

The aim of this study is to understand how capacity building works. The authors will use realist evaluation to evaluate an intervention in Karnataka, India. The intervention is a capacity-building programme that seeks to improve management capacities of health managers at district and subdistrict levels through periodic classroom-based teaching and mentoring support at the workplace. The authors conducted interviews and reviewed literature on capacity building in health to draw out the programme theory of the intervention. Based on this, the authors formulated hypothetical pathways connecting the expected outcomes of the intervention (planning and supervision) to the inputs (contact classes and mentoring). The authors prepared a questionnaire to assess elements of the programme theory-organisational culture, self-efficacy and supervision. The authors shall conduct a survey among health managers as well as collect qualitative data through interviews with participants and non-participants selected purposively based on their planning and supervision performance. The authors will construct explanations in the form of context-mechanism-outcome configurations from the results. This will be iterative and the authors will use a realist evaluation framework to refine the explanatory theories that are based on the findings to explain and validate an improved theory on 'what works for whom and under what conditions'.

DISCUSSION

The scope for applying realist evaluation to study human resource management interventions in health are discussed.

The Health System Dynamics Framework: The introduction of an analytical model for health system analysis and its application to two case-studies

Frameworks can clarify concepts and improve understanding of underlying mechanisms in the domain of health systems research and strengthening. Many existing frameworks have a limited capacity to analyze interactions and equilibriums within a health system overlooking values as an underlying steering mechanism. This paper introduces the health system dynamics framework and demonstrates its application as a tool for analysis and modelling. The added value of this framework is: 1) consideration of different levels of a health system and tracing how interventions or events at one level influence other elements and other levels; 2) emphasizes the importance of values; 3) a central axis linking governance, human resources, service delivery and population, and 4) taking into account the key elements of complexity in analysis and strategy development. We urge  the analysis of individual health systems and meta-analysis, for a better understanding of their functioning and strengthening. 

Abolition of user fees: the Uganda paradox

Inadequate health financing is one of the major challenges health systems in low-income countries currently face. Health financing reforms are being implemented with an increasing interest in policies that abolish user fees. Data from three nationally representative surveys conducted in Uganda in 1999/2000, 2002/03 and 2005/06 were used to investigate the impact of user fee abolition on the attainment of universal coverage objectives. An increase in illness reporting was noted over the three surveys, especially among the poorer quintiles. An increase in utilization was registered in the period immediately following the abolition of user fees and was most pronounced in the poorest quintile. Overall, there was an increase in utilization in both public and private health care delivery sectors, but only at clinic and health centre level, not at hospitals. Our study shows important changes in health-care-seeking behaviour. In 2002/03, the poorest population quintile started using government health centres more often than private clinics whereas in 1999/2000 private clinics were the main source of health care. The richest quintile has increasingly used private clinics. Overall, it appears that the private sector remains a significant source of health care. Following abolition of user fees, we note an increase in the use of lower levels of care with subsequent reductions in use of hospitals. Total annual average expenditures on health per household remained fairly stable between the 1999/2000 and 2002/03 surveys. There was, however, an increase of US$21 in expenditure between the 2002/03 and 2005/06 surveys. Abolition of user fees improved access to health services and efficiency in utilization. On the negative side is the fact that financial protection is yet to be achieved. Out-of-pocket expenditure remains high and mainly affects the poorer population quintiles. A dual system seems to have emerged where wealthier population groups are switching to the private sector.

Research, evidence and policymaking: the perspectives of policy actors on improving uptake of evidence in health policy development and implementation in Uganda

Background

Use of evidence in health policymaking plays an important role, especially in resource-constrained settings where informed decisions on resource allocation are paramount. Several knowledge translation (KT) models have been developed, but few have been applied to health policymaking in low income countries. If KT models are expected to explain evidence uptake and implementation, or lack of it, they must be contextualized and take into account the specificity of low income countries for example, the strong influence of donors. The main objective of this research is to elaborate a Middle Range Theory (MRT) of KT in Uganda that can also serve as a reference for other low- and middle income countries.

Methods

This two-step study employed qualitative approaches to examine the principal barriers and facilitating factors to KT. Step 1 involved a literature review and identification of common themes. The results informed the development of the initial MRT, which details the facilitating factors and barriers to KT at the different stages of research and policy development. In Step 2, these were further refined through key informant interviews with policymakers and researchers in Uganda. Deductive content and thematic analysis was carried out to assess the degree of convergence with the elements of the initial MRT and to identify other emerging issues.

Results

Review of the literature revealed that the most common emerging facilitating factors could be grouped under institutional strengthening for KT, research characteristics, dissemination, partnerships and political context. The analysis of interviews, however, showed that policymakers and researchers ranked institutional strengthening for KT, research characteristics and partnerships as the most important. New factors emphasized by respondents were the use of mainstreamed structures within MoH to coordinate and disseminate research, the separation of roles between researchers and policymakers, and the role of the community and civil society in KT.

Conclusions

This study refined an initial MRT on KT in policymaking in the health sector in Uganda that was based on a literature review. It provides a framework that can be used in empirical research of the process of KT on specific policy issues.

Positive spill-over effects of ART scale up on wider health systems development: evidence from Ethiopia and Malawi

Background

Global health initiatives have enabled the scale up of antiretroviral treatment (ART) over recent years. The impact of HIV-specific funds and programmes on non-HIV-related health services and health systems in genera has been debated extensively. Drawing on evidence from Malawi and Ethiopia, this article analyses the effects of ART scale-up interventions on human resources policies, service delivery and general health outcomes, and explores how synergies can be maximized.

Methods

Data from Malawi and Ethiopia were compiled between 2004 and 2009 and between 2005 and 2009, respectively. We developed a conceptual health systems framework for the analysis. We used the major changes in human resources policies as an entry point to explore the wider health systems changes.

Results

In both countries, the need for an HIV response triggered an overhaul of human resources policies. As a result, the health workforce at health facility and community level was reinforced. The impact of this human resources trend was felt beyond the scale up of ART services; it also contributed to an overall increase in functional health facilities providing curative, mother and child health, and ART services. In addition to a significant increase in ART coverage, we observed a remarkable rise in user rates of non-HIV health services and an improvement in overall health outcomes.

Conclusions

Interventions aimed at the expansion of ART services and improvement of long-term retention of patients in ART care can have positive spill-over effects on the health system. The responses of Malawi and Ethiopia to their human resources crises was exceptional in many respects, and some of the lessons learnt can be useful in other contexts. The case studies show the feasibility of obtaining improved health outcomes beyond HIV through scaled-up ART interventions when these are part of a long-term, system-wide health plan supported by all decision makers and funders.

Political will for better health, a bottom-up process

Lately, different voices in the global public health community have drawn attention to the interaction between the State and civil society in the context of reducing health inequities. A rights-based approach empowers people not only to claim their rights but also to demand accountability from the State. Lessons from history show that economic growth does not automatically have positive implications for population health. It may even be disruptive in the absence of strong stewardship and regulation by national and local public health authorities. The field research in which we have been involved over the past 20 years in the Philippines, Palestine, Cuba, and Europe confirms that organized communities and people's organizations can effectively pressure the state into action towards realizing the right to health. Class analysis, influencing power relations, and giving the State a central role have been identified as three key strategies of relevant social movements and NGOs. More interaction between academia and civil society organizations could contribute to enhance and safeguard the societal relevance of public health researches. Our own experience made us discover that social movements and public health researchers have a lot to learn from one another.

The interface between health systems and vertical programmes in Francophone Africa: the managers' perceptions

OBJECTIVE

To explores the interface between vertical programmes (VPs) and general health services (GHS) in sub-Saharan Africa.

METHODS

Using semi-structured interviews, we analysed the perceptions of a selection of experienced mid-level managers of health systems and of VP originating in francophone Africa on the nature and quality of this interface.

RESULTS

The respondents acknowledged that VPs lead to both positive and negative effects on the functioning of GHS. The overall result, however, cannot be viewed as a simple summation of the positive effects possibly compensating for the negative ones. Indeed, some of the negative effects have a profound impact on the management and operation of the health care delivery system and may undermine the long-term institutional capacity of the general health systems. The quality and the nature of the interface between VP and GHS strongly vary in time, between settings and programmes.

CONCLUSION

We argue for more systematic monitoring of the interface between VP and GHS, so as to identify and address, in a timely manner, significant disruptive effects and deficiencies in a perspective of systemic capacity building of health systems.

Community health insurance schemes & patient satisfaction--evidence from India

BACKGROUND & OBJECTIVES

Quality of care is an important determinant for utilizing health services. In India, the quality of care in most health services is poor. The government recognizes this and has been working on both supply and demand aspects. In particular, it is promoting community health insurance (CHI) schemes, so that patients can access quality services. This observational study was undertaken to measure the level of satisfaction among insured and uninsured patients in two CHI schemes in India.

METHODS

Patient satisfaction was measured, which is an outcome of good quality care. Two CHI schemes, Action for Community Organisation, Rehabilitation and Development (ACCORD) and Kadamalai Kalanjiam Vattara Sangam (KKVS), were chosen. Randomly selected, insured and uninsured households were interviewed. The household where a patient was admitted to a hospital was interviewed in depth about the health seeking behaviour, the cost of treatment and the satisfaction levels.

RESULTS

It was found that at both ACCORD and KKVS, there was no significant difference in the levels of satisfaction between the insured and uninsured patients. The main reasons for satisfaction were the availability of doctors and medicines and the recovery by the patient.

INTERPRETATION & CONCLUSIONS

Our study showed that insured hospitalized patients did not have significantly higher levels of satisfaction compared to uninsured hospitalized patients. If CHI schemes want to improve the quality of care for their clients, so that they adhere to the scheme, the scheme managers need to negotiate actively for better quality of care with empanelled providers.

La carte sanitaire de la ville de Lubumbashi, République Démocratique du Congo Partie II : analyse des activités opérationnelles des structures de soins

Les structures de santé dans la ville de Lubumbashi tentent d’offrir à la population des soins de santé en réponse à ses besoins ressentis. Cet article présente et analyse la nature et le volume des soins offerts par les différents prestataires institutionnels aux différents niveaux du système de santé pour l’ensemble de l’année 2006. Pratiquement toutes les structures offrent des soins curatifs. Le taux d’utilisation moyen pour l’ensemble de la ville est de 0,37 nouveaux cas par habitant par an. La population utilise plus souvent l’hôpital que les structures intermédiaires et celles de première ligne. Des maternités sont disponibles dans près de 2/3 des structures de première ligne, dans toutes les structures intermédiaires et dans tous les hôpitaux. Neuf accouchements sur dix sont assistés avec un taux de césarienne de moins de 2%. La vaccination est réalisée dans 2/3 des structures de première ligne avec un taux de couverture de la 3ème dose du vaccin trivalent contre la diphtérie, le tetanos et la coqueluche (DTC3) de 49%. Seulement quelques structures de première ligne dépistent les cas de tuberculose pulmonaire à microscopie positive avec un taux de dépistage de 44%. La présente étude, basée sur une mesure quantitative, met en évidence une discordance entre l’offre et la demande. Elle contribue à une meilleure compréhension de l’offre de soins à Lubumbashi même si les questions de la qualité des soins et de l’accessibilité financière aux soins restent encore en suspens.

La carte sanitaire de la ville de Lubumbashi, République Démocratique du Congo Partie I : problématique de la couverture sanitaire en milieu urbain congolais

Cet article fait l’inventaire physique de toutes les structures de soins existantes dans la ville de Lubumbashi en 2006, étudie l’évolution de leur apparition dans le temps, détermine leur répartition géographique et identifie les différents prestataires institutionnels et opérationnels qui y travaillent. Une enquête de terrain a permis de collecter des informations se rapportant à ces objectifs pour l’année 2006. Les résultats révèlent une augmentation annuelle du nombre des structures de soins et leur concentration vers le centre-ville ; une grande diversité institutionnelle des prestataires (Etat, confessions religieuses, ONG locales, entreprises paraétatiques et privés indépendants) ; une évolution exponentielle du nombre de structures de première ligne et une croissance de la pratique médicalisée dans ces structures ; une marginalisation de l’Etat comme prestataire de première ligne (moins de 10% de l’offre) mais qui reste néanmoins prestataire majoritaire dans l’offre de soins hospitaliers (51% de lits d’hospitalisation). Ces résultats plaident pour une évolution dans les rôles de l’Etat : celui-ci devrait se concentrer en priorité sur l’offre de soins hospitaliers, ensuite sur son rôle de démonstration des bonnes pratiques en première ligne et enfin sur la régulation de l’offre privée de soins de première ligne.

Community health insurance amidst abolition of user fees in Uganda: the view from policy makers and health service managers

Background

This paper investigates knowledge of Community Health Insurance (CHI) and the perception of its relevance by key policy makers and health service managers in Uganda. Community Health Insurance schemes currently operate in the private-not-for-profit sector, in settings where church-based facilities function. They operate in a wider policy environment where user fees in the public sector have been abolished.

Methods

Semi-structured interviews were conducted during the second half of 2007 with District Health Officers (DHOs) and senior staff of the Ministry of Health (MOH). The qualitative data collected were analyzed using the framework method, facilitated by EZ-Text software.

Results

There is poor knowledge and understanding of CHI activities by staff of the MOH headquarters and DHOs. However, a comparison of responses reveals a relatively high level of awareness of CHI principles among DHOs compared to that of MOH staff. All the DHOs in the districts with schemes had a good understanding of CHI principles compared to DHOs in districts without schemes. Out-of-pocket expenditure remains an important feature of health care financing in Uganda despite blanket abolition of user fees in government facilities.

Conclusion

CHI is perceived as a relevant policy option and potential source of funds for health care. It is also considered a means of raising the quality of health care in both public and private health units. To assess whether it is also feasible to introduce CHI in the public sector, there is an urgent need to investigate the willingness and readiness of stakeholders, in particular high level political authorities, to follow this new path. The current ambiguity and contradictions in the health financing policy of the Uganda MOH need to be addressed and clarified.

Community health insurance in Gudalur, India, increases access to hospital care

BACKGROUND

To reduce the burden of out-of-pocket payments on households in India, the government has introduced community health insurance (CHI) as part of its National Rural Health Mission. Indian CHI schemes have been shown to provide financial protection and have the potential to improve quality of care, but do not seem to improve access. This study examines this dimension of CHI performance and explores conditions under which a CHI scheme can improve access to hospital care for the poor.

METHODS

We conducted a panel survey at the ACCORD-AMS-ASHWINI (AAA) CHI scheme in India. The AAA CHI scheme protects the poorest sections of society against hospitalization expenses. 297 insured and 248 matched uninsured households were observed by village volunteers on a weekly basis for 12 months. Any patient presenting with a 'major ailment' in these households was interviewed using a structured questionnaire. Outcomes measured were utilization of hospital services, cost of treatment and quality of treatment received.

RESULTS

The two cohorts were similar regarding demographic, social and economic parameters. More insured than uninsured households expressed trust in the CHI scheme organizers. Both groups had similar levels of minor ailments, but the insured had higher incidence of chronic and major ailments. Insured patients had a hospital admission rate 2.2 times higher than uninsured patients, independent of confounding factors. This higher rate among the insured was also found in children and those with pre-existing conditions. Vulnerable sections of the insured population-children, pregnant women, the poorest-had the highest admission rates. Most admissions, in both cohorts, took place in the ASHWINI hospital. Credible and trustworthy organizers, effective providers, low co-payments, and low indirect costs contributed to this result.

CONCLUSIONS

A well-designed CHI scheme has the potential to improve access to hospital care, even for vulnerable sections of the community-the poorest, individuals with pre-existing conditions like diabetes and hypertension, and pregnant women.

What are the emerging features of community health insurance schemes in East Africa?

Background

The three East African countries of Uganda, Tanzania, and Kenya are characterized by high poverty levels, population growth rates, prevalence of HIV/AIDS, under-funding of the health sector, poor access to quality health care, and small health insurance coverage. Tanzania and Kenya have user-fees whereas Uganda abolished user-fees in public-owned health units.

Objective

To provide comparative description of community health insurance (CHI) schemes in three East African countries of Uganda, Tanzania, and Kenya and thereafter provide a basis for future policy research for development of CHI schemes.

Methods

An analytical grid of 10 distinctive items pertaining to the nature of CHI schemes was developed so as to have a uniform lens of comparing country situations of CHI.

Results and conclusions

The majority of the schemes have been in existence for a relatively short time of less than 10 years and their number remains small. There is need for further research to identify what is the mix and weight of factors that cause people to refrain from joining schemes. Specific issues that could also be addressed in subsequent studies are whether the current schemes provide financial protection, increase access to quality of care and impact on the equity of health services financing and delivery. On the basis of this knowledge, rational policy decisions can be taken. The governments thereafter could consider an option of playing more roles in advocacy, paying for the poorest, and developing an enabling policy and legal framework.

Community health insurance in Uganda: why does enrolment remain low? A view from beneath

Community Health Insurance (CHI) in Uganda faces low enrolment despite interest by the Ugandan health sector to have CHI as an elaborate health sector financing mechanism. User fees have been abolished in all government facilities and CHI in Uganda is limited to the private not for profit sub-sector, mainly church-related rural hospitals. In this study, the reasons for the low enrolment are investigated in two different models of CHI. Focus group discussions and in-depth interviews were carried out with members and non-members of CHI schemes in order to acquire more insight and understanding in people's perception of CHI, in their reasons for joining and not joining and in the possibilities they see to increase enrolment. This study, which is unprecedented in East Africa, clearly points to a mixed understanding on the basic principles of CHI and on the routine functioning of the schemes. The lack of good information is mentioned by many. Problems in ability to pay the premium, poor quality of health care, the rigid design in terms of enrolment requirements and problems of trust are other important reasons for people not to join. Our findings are grossly in line with the results of similar studies conducted in West Africa even if a number of context-specific issues have been identified. The study provides relevant elements for the design of a national policy on CHI in Uganda and other sub-Saharan countries.

Low enrollment in Ugandan Community Health Insurance schemes: underlying causes and policy implications

Background

Despite the promotion of Community Health Insurance (CHI) in Uganda in the second half of the 90's, mainly under the impetus of external aid organisations, overall membership has remained low. Today, some 30,000 persons are enrolled in about a dozen different schemes located in Central and Southern Uganda. Moreover, most of these schemes were created some 10 years ago but since then, only one or two new schemes have been launched. The dynamic of CHI has apparently come to a halt.

Methods

A case study evaluation was carried out on two selected CHI schemes: the Ishaka and the Save for Health Uganda (SHU) schemes. The objective of this evaluation was to explore the reasons for the limited success of CHI. The evaluation involved review of the schemes' records, key informant interviews and exit polls with both insured and non-insured patients.

Results

Our research points to a series of not mutually exclusive explanations for this under-achievement at both the demand and the supply side of health care delivery. On the demand side, the following elements have been identified: lack of basic information on the scheme's design and operation, limited understanding of the principles underlying CHI, limited community involvement and lack of trust in the management of the schemes, and, last but not least, problems in people's ability to pay the insurance premiums. On the supply-side, we have identified the following explanations: limited interest and knowledge of health care providers and managers of CHI, and the absence of a coherent policy framework for the development of CHI.

Conclusion

The policy implications of this study refer to the need for the government to provide the necessary legislative, technical and regulative support to CHI development. The main policy challenge however is the need to reconcile the government of Uganda's interest in promoting CHI with the current policy of abolition of user fees in public facilities.