Vertical vs horizontal health programmes in Africa: idealism, pragmatism, resources and efficiency

Theories, determinants, and intervention models and approaches on inequalities of undernutrition amongst under fives: A literature review

Background and Aims

One of the greatest public health problems of the 21st century is undernutrition in children under the age of 5 years (CAUFY). Globally, over 232 million CUAFY are undernourished and approximately 45% of mortality in this population are undernutrition-induced. This paper reviewed and critically explained the factors perpetuating undernutrition in CUAFY in the global space. It further explained the multi-level determinants that influence health inequalities and consequently exacerbate undernutrition amongst CUAFY globally. It also went further to explain the intervention models and approaches that can be used to tackle undernutrition in CUAFY.

Methods/Literature Search Strategy

Demiris et al.'s approach to narrative review was utilized for this paper. Relevant articles on child nutrition were retrieved from multiple credible databases and websites of foremost health organizations. Using an iterative process, multiple combinations of search terms were done by stringing relevant key terms and their synonyms with Boolean Operators. This process was constantly refined to align search results with the study aim. Database search produced relevant and resourceful publications which were utilized to develop this review.

Results

The global burden of undernutrition remains high, especially in Oceania with the highest prevalence of stunting and wasting (41.4% and 12.5%), with Africa and Asia following closely. Malnutrition eradication is a global health issue of high priority as demonstrated by the "Goal 2" of the Sustainable Development Goals (SDGs), and the United Nations (UN) Decade of Action on Nutrition 2016-2025. The review identified no significant positive outcome from previous interventions due to the endemic health inequalities. Determinants of the multi-level health inequalities associated with undernutrition in CUAFY, and probable solutions are explained with theoretical models of health inequalities. A diagonal intervention approach was proposed as a viable solution to ending undernutrition in CUAFY.

Conclusion

The application of relevant theoretical models and context-specific intervention approaches can be utilized by stakeholders to close the existing inequality gaps, thereby reducing undernutrition amongst CUAFY globally.

Medical disposals and problem solving: About high blood pressure in Morocco

In this article, I analyze how in basic health-care facilities in Morocco, general practitioners transform patients' problems into solvable problems, taking into account constraints related to medical standards, financial issues, the organization of the health system, and care. My focus is on hypertension, or high blood pressure. I argue that standards allow the solving of patients' problems through the production of an entity called high blood pressure. However, the 'high blood pressure' enacted is different from the entity defined by standards. Fragments of the latter, borrowed from other contexts, are put to work in Morocco, while the material arrangements needed to enforce and have them work without discontinuities do not exist. This contributes to the production of an entity configured at a moment in time between standards and patients' lives.

European aid and health system strengthening: an analysis of donor approaches in the DRC, Ethiopia, Uganda, Mozambique and the global fund

Background: In the field of international health assistance (IHA), there is a growing consensus on the limits of disease-specific interventions and the need for more health system strengthening (HSS). European donors are considered to be strong supporters of HSS. Nevertheless, little is known about how their support for HSS translates into concrete policies at partner country level. Furthermore, as development cooperation is a shared policy between the EU and its Member States, it remains unclear to what extent European donors share a similar approach.

Objective: This article reviews a PhD thesis on European aid and HSS. The thesis investigated (1) the approaches of European donors towards IHA, and (2) the extent to which there are similarities or differences between them. An original analytical framework was developed to make a fine-grained analysis of European donors’ approaches in the DRC, Ethiopia, Uganda and Mozambique. In addition, the relation of European donors with the Global Fund was investigated.

Methods: An abductive research approach was used during which literature review, data generation, analysis and research design mutually influenced each other. The research built on a wide range of empirical data, including semi-structured interviews with 123 respondents, policy documents and descriptive statistical analysis.

Results and conclusion: Four ‘types’ of European donors were identified, which vary in their focus (issue-specific versus comprehensive) and their level of support to and involvement of recipient states. Despite this heterogeneity at a specific level, there is still a general degree of ‘unity’ among European donors, especially compared with the US. Yet, there are signs that the ‘transatlantic’ divide on HSS may be converging, as European donors tend to focus more explicitly on result-oriented approaches traditionally associated with the US and Global Health Initiatives. Consequently, European donors play a limited role in bringing HSS more to the forefront in IHA.

Public health law coverage in support of the health-related sustainable development goals (SDGs) among 33 Western Pacific countries

Background

A resilient health system is inevitable in attaining the health-related Sustainable Development Goals (SDGs). One way of strengthening health systems is improving the coverage of public health laws for better health governance. The aim of this study is to describe the public health law situation in the Western Pacific Region and analyse the association of public health law coverage with health-related SDGs statistics.

Methods

A total of 33 Western Pacific countries were selected and analysed using a multi-group ecological study design. Public health law coverage was measured from April 2013 to October 2016 based on the public health law coverage module in the ‘Tool to Assess Health Law’ developed by the WHO Western Pacific Regional Office and Asian Institute for Bioethics and Health Law of Yonsei University. The health-related SDGs status were examined using health statistics data from World Health Statistics 2017 and 2018 by WHO and SDGs index scores of previous research.

Results

Countries with high public health law coverage were Vietnam, Republic of Korea, Hong Kong, and Singapore. Low coverage countries were mainly Pacific Island countries. High public health law coverage issues were health care organisation, communicable diseases, and substance abuse, whereas those of low coverage were human reproduction, family health, and oral health. Public health law coverage was associated with health-related SDGs statistics such as life expectancy at birth (r = 0.47, p = 0.03), health life expectancy at birth (r = 0.47, p = 0.04), health-related SDGs index (r = 0.43, p = 0.05). Among the SDG 3 indicators, maternal mortality ratio (r = − 0.53, p = 0.01), neonatal mortality rate (r = − 0.44, p = 0.02), new HIV infections (r = 0.78, p = 0.04), total alcohol consumption (r = 0.45, p = 0.02), adolescent birth rate (r = − 0.40, p = 0.04), UHC service coverage index (r = 0.50, p = 0.02), and IHR average core capacity score (r = 0.54, p = 0.004) were statistically meaningful. However, there was no association of public health law coverage with health statistics in other SDGs.

Conclusions

This study proved the importance of public health law in supporting the attainment of health-related SDGs. These results should be used as the basis for review and action at country level in improving public health law for better health systems, consequently achieving health-related SDGs.

A strong TB programme embedded in a developing primary healthcare system is a lose-lose situation: insights from patient and community perspectives in Cambodia

As exemplified by the situation in Cambodia, disease specific (vertical) health programmes are often favoured when the health system is fragile. The potential of such an approach to impede strengthening of primary healthcare services has been studied from a health systems perspective in terms of access and quality of care. In this bottom-up, qualitative study we investigate patient and community member experiences of health services when a strong tuberculosis (TB) programme is embedded into a relatively underutilized primary healthcare system. We conducted six gender-stratified community focus group discussions (n = 49) and seven mixed-gender focus group discussions with TB patients (n = 45) in three provinces located in urban, peri-urban and rural areas of Cambodia. Our analysis of health-seeking behaviour and experiences for TB and TB-like illness indicates that building a strong vertical TB control programme has had numerous benefits, including awareness of typical symptoms and need to seek care early; confidence in free TB services at public facilities; and willingness to complete treatment. However, there was a clear dichotomy in experiences and behaviour with respect to care-seeking for less severe illness at primary health services, which were generally avoided owing to access barriers and perceived poor quality. The tendency to delay seeking health care until the development of severe symptoms clearly indicative of TB is a major barrier to early diagnosis and treatment of TB. Our study indicates that an imbalance in the strength of vertical and primary health services could be a lose-lose situation as this impedes improvements in health system functioning and constrains progress of vertical disease control programmes.

Integration of antenatal care services with health programmes in low- and middle-income countries: systematic review

Background

Antenatal care (ANC) presents a potentially valuable platform for integrated delivery of additional health services for pregnant women–services that are vital to reduce the persistently high rates of maternal and neonatal mortality in low– and middle–income countries (LMICs). However, there is limited evidence on the impact of integrating health services with ANC to guide policy. This review assesses the impact of integration of postnatal and other health services with ANC on health services uptake and utilisation, health outcomes and user experience of care in LMICs.

Methods

Cochrane Library, MEDLINE, Embase, CINAHL Plus, POPLINE and Global Health were searched for studies that compared integrated models for delivery of postnatal and other health services with ANC to non–integrated models. Risk of bias of included studies was assessed using the Cochrane Effective Practice and Organisation of Care (EPOC) criteria and the Newcastle–Ottawa Scale, depending on the study design. Due to high heterogeneity no meta–analysis could be conducted. Results are presented narratively.

Findings

12 studies were included in the review. Limited evidence, with moderate– to high–risk of bias, suggests that integrated service delivery results in improved uptake of essential health services for women, earlier initiation of treatment, and better health outcomes. Women also reported improved satisfaction with integrated services.

Conclusions

The reported evidence is largely based on non–randomised studies with poor generalizability, and therefore offers very limited policy guidance. More rigorously conducted and geographically diverse studies are needed to better ascertain and quantify the health and economic benefits of integrating health services with ANC.

Integrated care: learning between high-income, and low- and middle-income country health systems

Over the past decade, discussion of integrated care has become more widespread and prominent in both high- and low-income health care systems (LMICs). The trend reflects the mismatch between an increasing burden of chronic disease and local health care systems which are still largely focused on hospital-based treatment of individual clinical episodes and also the long-standing proliferation of vertical donor-funded disease-specific programmes in LMICs which have disrupted horizontal, or integrated, care. Integration is a challenging concept to define, in part because of its multiple dimensions and varied scope: from integrated clinical care for individual patients to broader systems integration-or linkage-involving a wide range of interconnected services (e.g. social services and health care). In this commentary, we compare integrated care in high- and lower-income countries. Although contexts may differ significantly between these settings, there are many common features of how integration has been understood and common challenges in its implementation. We discuss the different approaches to, scope of, and impacts of, integration including barriers and facilitators to the processes of implementation. With the burden of disease becoming more alike across settings, we consider what gains there could be from comparative learning between these settings which have constituted two separate strands of research until now.

Diabetes in sub-Saharan Africa - from policy to practice to progress: targeting the existing gaps for future care for diabetes

The global prevalence and impact of diabetes has increased dramatically, particularly in sub-Saharan Africa. This region faces unique challenges in combating the disease including lack of funding for noncommunicable diseases, lack of availability of studies and guidelines specific to the population, lack of availability of medications, differences in urban and rural patients, and inequity between public and private sector health care. Because of these challenges, diabetes has a greater impact on morbidity and mortality related to the disease in sub-Saharan Africa than any other region in the world. In order to address these unacceptably poor trends, contextualized strategies for the prevention, identification, management, and financing of diabetes care within this population must be developed. This narrative review provides insights into the policy landscape, epidemiology, pathophysiology, care protocols, medication availability, and health care systems to give readers a comprehensive summary of many factors in these domains as they pertain to diabetes in sub-Saharan Africa. In addition to providing a review of the current evidence available in these domains, potential solutions to address the major gaps in care will be proposed to reverse the negative trends seen with diabetes in sub-Saharan Africa.

Conceptualizing Care Continua: Lessons from HIV, Hepatitis C Virus, Tuberculosis and Implications for the Development of Improved Care and Prevention Continua

Background

To examine the application of continuum models to tuberculosis, HIV, and other conditions; to theorize the concept of continua; and to learn lessons that could inform the development of improved care and prevention continua as public health metrics.

Methods

An analytic review of literature drawn from several fields of health care.

Results

The continuum construct is now part of public health evaluation systems for HIV, and is increasingly used in public health and the medical literature. Issues with the comparability and optimal design of care continuum models have been raised, and their methodologic and theoretic underpinnings and scope of focus have been under-addressed. Review of relevant publications suggests that a key limitation of current models is their lack of measures reflecting incidence and mortality. Issues relating to continua data being longitudinal or cross-sectional, definition of numerators and denominators for each step, data sources, measures of timeliness of step completion, theoretic models to facilitate inferences of causes of care continuum gaps, how measures of prevention efforts, reinfection/relapses, and interactions of continua for co-occurring comorbidities should be reflected, and how analyses of differences in retention over time, across geographic regions, and in response to interventions should be conducted are critical to the development of sound care and prevention continuum models.

Conclusion

Lessons learned from the application of continuum models to HIV and other conditions suggest that the application of well-formulated constructs of care and prevention continua, that depict, in well defined, standardized steps, incidence and mortality, along with degrees of and time to screening, engagement in care and prevention, treatment and treatment outcomes, including relapse or reinfection, may be vital tools in evaluating intervention and program outcomes, and in improving population health and population health metrics for a wide range conditions.

Influence of Organizational Structure and Administrative Processes on the Performance of State-Level Malaria Programs in Nigeria

Abstract-Studies have found links between organizational structure and performance of public organizations. Considering the wide variation in uptake of malaria interventions and outcomes across Nigeria, this exploratory study examined how differences in administrative location (a dimension of organizational structure), the effectiveness of administrative processes (earmarking and financial control, and communication), leadership (use of data in decision making, state ownership, political will, and resourcefulness), and external influences (donor influence) might explain variations in performance of state malaria programs in Nigeria. We hypothesized that states with malaria program administrative structures closer to state governors will have greater access to resources, greater political support, and greater administrative flexibility and will therefore perform better. To assess these relationships, we conducted semistructured interviews across three states with different program administrative locations: Akwa-Ibom, Cross River, and Niger. Sixty-five participants were identified through a snowballing approach. Data were analyzed using a thematic framework. State program performance was assessed across three malaria service delivery domains (prevention, diagnosis, and treatment) using indicators from Nigeria Demographic and Health Surveys conducted in 2008 and 2013. Cross River State was best performing based on 2013 prevention data (usage of insecticide-treated bednets), and Niger State ranked highest in diagnosis and treatment and showed the greatest improvement between 2008 and 2013. We found that organizational structure (administrative location) did not appear to be determinative of performance but rather that the effectiveness of administrative processes (earmarking and financial control), strong leadership (assertion of state ownership and resourcefulness of leaders in overcoming bottlenecks), and donor influences differed across the three assessed states and may explain the observed varying outcomes.

How should the post-2015 response to AIDS relate to the drive for universal health coverage?

The drive for universal health coverage (UHC) now has a great deal of normative impetus, and in combination with the inauguration of the sustainable development goals, has come to be regarded as a means of ensuring the financial basis for the struggle against HIV and AIDS. The argument of this paper is that such thinking is a case of 'the right thing at the wrong time': it seriously underestimates the scale of the work against HIV and AIDS, and the speed with which we need to undertake it, if we are to consolidate the gains we have made to date, let alone reduce it to manageable proportions. The looming 'fiscal crunch' makes the challenges all the more daunting; even in the best circumstances, the time required to establish UHCs capable of providing both essential health services and a very rapid scale-up of the fight against HIV and AIDS is insufficient when set against the urgency of ensuring that AIDS does not eventuate as a global health catastrophe.

Aspirations and realities in a North-South partnership for health promotion: lessons from a program to promote safe male circumcision in Botswana

BACKGROUND

International donors support the partnership between the Government of Botswana and two international organisations: U.S. Centers for Disease Control and Prevention and Africa Comprehensive HIV/AIDS Partnership to implement Voluntary Medical Male Circumcision with the target of circumcising 80 % of HIV negative men in 5 years. Botswana Government had started integration of the program into its health system when international partners brought in the Models for Optimizing Volume and Efficiency to strengthen delivery of the service and push the target. The objective of this paper is to use a systems model to establish how the functioning of the partnership on Safe Male Circumcision in Botswana contributed to the outcome.

METHODS

Data were collected using observations, focus group discussions and interviews. Thirty participants representing all three partners were observed in a 3-day meeting; followed by three rounds of in-depth interviews with five selected leading officers over 2 years and three focus group discussions.

RESULTS

Financial resources, "ownership" and the target influence the success or failure of partnerships. A combination of inputs by partners brought progress towards achieving set program goals. Although there were tensions between partners, they were working together in strategising to address some challenges of the partnership and implementation. Pressure to meet the expectations of the international donors caused tension and challenges between the in-country partners to the extent of Development Partners retreating and not pursuing the mission further.

CONCLUSION

Target achievement, the link between financial contribution and ownership expectations caused antagonistic outcome. The paper contributes enlightenment that the functioning of the visible in-country partnership is significantly influenced by the less visible global context such as the target setters and donors.

Towards health equity: a framework for the application of proportionate universalism

Introduction

The finding that there is a social gradient in health has prompted considerable interest in public health circles. Recent influential works describing health inequities and their causes do not always argue cogently for a policy framework that would drive the most appropriate solutions differentially across the social gradient This paper aims to develop a practice heuristic for proportionate universalism.

Methods

Through a review the proposed heuristic integrates evidence from welfare state and policy research, the literature on universal and targeted policy frameworks, and a multi-level governance approach that adopts the principle of subsidiarity.

Results

The proposed heuristic provides a more-grained analysis of different policy approaches, integral for operationalizing the concept of proportionate universalism.

Conclusion

The proposed framework would allow governments at all levels, social policy developers and bureaucrats, public health professionals and activists to consider the appropriateness of distinctive policy objectives across distinctive population needs within universal welfare state principles.

Diagnosis of neglected tropical diseases among patients with persistent digestive disorders (diarrhoea and/or abdominal pain ≥14 days): Pierrea multi-country, prospective, non-experimental case-control study

Background

Diarrhoea still accounts for considerable mortality and morbidity worldwide. The highest burden is concentrated in tropical areas where populations lack access to clean water, adequate sanitation and hygiene. In contrast to acute diarrhoea (<14 days), the spectrum of pathogens that may give rise to persistent diarrhoea (≥14 days) and persistent abdominal pain is poorly understood. It is conceivable that pathogens causing neglected tropical diseases play a major role, but few studies investigated this issue. Clinical management and diagnostic work-up of persistent digestive disorders in the tropics therefore remain inadequate. Hence, important aspects regarding the pathogenesis, epidemiology, clinical symptomatology and treatment options for patients presenting with persistent diarrhoea and persistent abdominal pain should be investigated in multi-centric clinical studies.

Methods/Design

This multi-country, prospective, non-experimental case–control study will assess persistent diarrhoea (≥14 days; in individuals aged ≥1 year) and persistent abdominal pain (≥14 days; in children/adolescents aged 1–18 years) in up to 2000 symptomatic patients and 2000 matched controls. Subjects from Côte d’Ivoire, Indonesia, Mali and Nepal will be clinically examined and interviewed using a detailed case report form. Additionally, each participant will provide a stool sample that will be examined using a suite of diagnostic methods (i.e., microscopic techniques, rapid diagnostic tests, stool culture and polymerase chain reaction) for the presence of bacterial and parasitic pathogens. Treatment will be offered to all infected participants and the clinical treatment response will be recorded. Data obtained will be utilised to develop patient-centred clinical algorithms that will be validated in primary health care centres in the four study countries in subsequent studies.

Discussion

Our research will deepen the understanding of the importance of persistent diarrhoea and related digestive disorders in the tropics. A diversity of intestinal pathogens will be assessed for potential associations with persistent diarrhoea and persistent abdominal pain. Different diagnostic methods will be compared, clinical symptoms investigated and diagnosis-treatment algorithms developed for validation in selected primary health care centres. The findings from this study will improve differential diagnosis and evidence-based clinical management of digestive syndromes in the tropics.

Trial registration

ClinicalTrials.gov; identifier: NCT02105714.

Determinants of performance of health systems concerning maternal and child health: a global approach

AIMS

To assess the association of social determinants on the performance of health systems around the world.

METHODS

A transnational ecological study was conducted with an observation level focused on the country. In order to research on the strength of the association between the annual maternal and child mortality in 154 countries and social determinants: corruption, democratization, income inequality and cultural fragmentation, we used a mixed linear regression model for repeated measures with random intercepts and a conglomerate-based geographical analysis, between 2000 and 2010.

RESULTS

Health determinants with a significant association on child mortality(<1year): higher access to water (βa Quartile 4(Q4) vs Quartile 1(Q1) = -6,14; 95%CI: -11,63 to -0,73), sanitation systems, (Q4 vs Q1 = -25,58; 95%CI: -31,91 to -19,25), % measles vaccination coverage (Q4 vs Q1 = -7.35; 95%CI: -10,18 to -4,52), % of births attended by a healthcare professional (Q4 vs Q1 = -7,91; 95%CI: -11,36 to -4,52) and a % of the total health expenditure (Q3 vs Q1 = -2,85; 95%CI: -4,93 to -0,7). Ethnic fragmentation (Q4 vs Q1 = 9,93; 95%CI: -0.03 to 19.89) had a marginal effect. For child mortality<5 years, an association was found for these variables and democratization (not free vs free = 11,23; 95%CI: -0,82 to 23,29), out-of-pocket expenditure (Q1 vs Q4 = 17,71; 95%CI: 5,86 to 29,56). For MMR (Maternal mortality ratio), % of access to water for all the quartiles, % of access to sanitation systems, (Q3 vs Q1 = -171,15; 95%CI: -281,29 to -61), birth attention by a healthcare professional (Q4 vs Q1 = -231,23; 95%CI: -349,32 to -113,15), and having corrupt government (Q3 vs Q1 = 83,05; 95%CI: 33,10 to 133).

CONCLUSIONS

Improving access to water and sanitation systems, decreasing corruption in the health sector must become priorities in health systems. The ethno-linguistic cultural fragmentation and the detriment of democracy turn out to be two factors related to health results.

The GAVI Alliance and the 'Gates approach' to health system strengthening

Lauded for getting specific health issues onto national and international agendas and for their potential to improve value for money and outcomes, public-private global health initiatives (GHIs) have come to dominate global health governance. Yet, they have also been criticised for their negative impact on country health systems. In response, disease-specific GHIs have, somewhat paradoxically, appropriated the aim of health system strengthening (HSS). This article critically analyses this development through an ethnographic case study of the GAVI Alliance, which funds vaccines in poor countries. Despite GAVI's self-proclaimed ‘single-minded’ focus on vaccines, HSS support is fronted as a key principle of GAVI's mission. Yet, its meaning remains unclear and contested understandings of the health systems agenda abound, reflecting competing public health ideologies and professional pressures within the global health field. Contrary to broader conceptualisations of HSS that emphasise social and political dimensions, GAVI's HSS support has become emblematic of the so-called ‘Gates approach’ to global health, focused on targeted technical solutions with clear, measurable outcomes. In spite of adopting rhetoric supportive of ‘holistic’ health systems, GHIs like GAVI have come to capture the global debate about HSS in favour of their disease-specific approach and ethos.

Communicable disease control programmes and health systems: an analytical approach to sustainability

There is renewed concern over the sustainability of disease control programmes, and re-emergence of policy recommendations to integrate programmes with general health systems. However, the conceptualization of this issue has remarkably received little critical attention. Additionally, the study of programmatic sustainability presents methodological challenges. In this article, we propose a conceptual framework to support analyses of sustainability of communicable disease programmes. Through this work, we also aim to clarify a link between notions of integration and sustainability. As a part of development of the conceptual framework, we conducted a systematic literature review of peer-reviewed literature on concepts, definitions, analytical approaches and empirical studies on sustainability in health systems. Identified conceptual proposals for analysis of sustainability in health systems lack an explicit conceptualization of what a health system is. Drawing upon theoretical concepts originating in sustainability sciences and our review here, we conceptualize a communicable disease programme as a component of a health system which is viewed as a complex adaptive system. We propose five programmatic characteristics that may explain a potential for sustainability: leadership, capacity, interactions (notions of integration), flexibility/adaptability and performance. Though integration of elements of a programme with other system components is important, its role in sustainability is context specific and difficult to predict. The proposed framework might serve as a basis for further empirical evaluations in understanding complex interplay between programmes and broader health systems in the development of sustainable responses to communicable diseases.

Integrating family planning services into HIV care and treatment clinics in Tanzania: evaluation of a facilitated referral model

BACKGROUND

Many clients of HIV care and treatment services have unmet contraceptive needs. Integrating family planning (FP) services into HIV services is an increasingly utilized strategy for meeting those unmet needs. However, numerous models for services integration are potentially applicable for clients with diverse health needs. This study developed and tested a 'facilitated referral' model for integrating FP into HIV care and treatment in Tanzania with the primary outcome being a reduction in unmet need for contraception among female clients.

METHODS

The facilitated referral model included seven distinct steps for service providers. A quasi-experimental, pre- and post-test, repeated cross-sectional study was conducted to evaluate the impact of the model. Female clients at 12 HIV care and treatment clinics (CTCs) were interviewed pre- and post-intervention and CTC providers were interviewed post-intervention.

RESULTS

A total of 323 CTC clients were interviewed pre-intervention and 299 were interviewed post-intervention. Among all clients, the adjusted decrease in proportion with unmet need (3%) was not significant (P = 0.103) but among only sexually active clients, the adjusted decrease (8%) approached significance (P = 0.052). Furthermore, the proportion of sexually active clients using a contraceptive method post-intervention increased by an estimated 12% (P = 0.013). Dual method use increased by 16% (P = 0.004). Increases were observed for all seven steps of the model from pre- to post-intervention. All providers (n = 45) stated that FP integration was a good addition although there were implementation challenges.

CONCLUSION

This study demonstrated that the facilitated referral model is a feasible strategy for integrating FP into HIV care and treatment services. The findings show that this model resulted in increased contraceptive use among HIV-positive female clients. By highlighting the distinct steps necessary for facilitated referrals, this study can help inform both programmes and future research efforts in services integration.

Integrating HIV care into nurse-led primary health care services in South Africa: a synthesis of three linked qualitative studies

Background

The integration of HIV care into primary care services is one of the strategies proposed to increase access to treatment for people living with HIV/AIDS in high HIV burden countries. However, how best to do this is poorly understood. This study documents different factors influencing models of integration within clinics.

Methods

Using methods based on the meta-ethnographic approach, we synthesised the findings from three qualitative studies of the factors that influenced integration of HIV care into all consultations in primary care. The studies were conducted amongst staff and patients in South Africa during a randomised trial of nurse initiation of antiretroviral therapy (ART) and integration of HIV care into primary care services – the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) trial. Themes from each study were identified and translated into each other to develop categories and sub-categories and then to inform higher level interpretations of the synthesised data.

Results

Clinics varied as to how HIV care was integrated. Existing administration systems, workload and support staff shortages tended to hinder integration. Nurses’ wanted to be involved in providing HIV care and yet also expressed preferences for developing expertise in certain areas and for establishing good nurse patient relationships by specialising in certain services. Patients, in turn, were concerned about the stigma of separate HIV services and yet preferred to be seen by nurses with expertise in HIV care. These factors had conflicting effects on efforts to integrate HIV care.

Conclusion

Local clinic factors and nurse and patient preferences in relation to care delivery should be taken into account in programmes to integrate HIV care into primary care services. The integration of medical records, monitoring and reporting systems would support clinic based efforts to integrate HIV care into primary care services.

The uptake of integrated perinatal prevention of mother-to-child HIV transmission programs in low- and middle-income countries: a systematic review

BACKGROUND

The objective of this review was to assess the uptake of WHO recommended integrated perinatal prevention of mother-to-child transmission (PMTCT) of HIV interventions in low- and middle-income countries.

METHODS AND FINDINGS

We searched 21 databases for observational studies presenting uptake of integrated PMTCT programs in low- and middle-income countries. Forty-one studies on programs implemented between 1997 and 2006, met inclusion criteria. The proportion of women attending antenatal care who were counseled and who were tested was high; 96% (range 30-100%) and 81% (range 26-100%), respectively. However, the overall median proportion of HIV positive women provided with antiretroviral prophylaxis in antenatal care and attending labor ward was 55% (range 22-99%) and 60% (range 19-100%), respectively. The proportion of women with unknown HIV status, tested for HIV at labor ward was 70%. Overall, 79% (range 44-100%) of infants were tested for HIV and 11% (range 3-18%) of them were HIV positive. We designed two PMTCT cascades using studies with outcomes for all perinatal PMTCT interventions which showed that an estimated 22% of all HIV positive women attending antenatal care and 11% of all HIV positive women delivering at labor ward were not notified about their HIV status and did not participate in PMTCT program. Only 17% of HIV positive antenatal care attendees and their infants are known to have taken antiretroviral prophylaxis.

CONCLUSION

The existing evidence provides information only about the initial PMTCT programs which were based on the old WHO PMTCT guidelines. The uptake of counseling and HIV testing among pregnant women attending antenatal care was high, but their retention in PMTCT programs was low. The majority of women in the included studies did not receive ARV prophylaxis in antenatal care; nor did they attend labor ward. More studies evaluating the uptake in current PMTCT programs are urgently needed.

Applying principles of health system strengthening to eye care

Understanding Health systems have now become the priority focus of researchers and policy makers, who have progressively moved away from a project-centred perspectives. The new tendency is to facilitate a convergence between health system developers and disease-specific programme managers in terms of both thinking and action, and to reconcile both approaches: one focusing on integrated health systems and improving the health status of the population and the other aiming at improving access to health care. Eye care interventions particularly in developing countries have generally been vertically implemented (e.g. trachoma, cataract surgeries) often with parallel organizational structures or specialised disease specific services. With the emergence of health system strengthening in health strategies and in the service delivery of interventions there is a need to clarify and examine inputs in terms governance, financing and management. This present paper aims to clarify key concepts in health system strengthening and describe the various components of the framework as applied in eye care interventions.

Administrative integration of vertical HIV monitoring and evaluation into health systems: a case study from South Africa

BACKGROUND

In light of an increasing global focus on health system strengthening and integration of vertical programmes within health systems, methods and tools are required to examine whether general health service managers exercise administrative authority over vertical programmes.

OBJECTIVE

To measure the extent to which general health service (horizontal) managers, exercise authority over the HIV programme's monitoring and evaluation (M&E) function, and to explore factors that may influence this exercise of authority.

METHODS

This cross-sectional survey involved interviews with 51 managers. We drew ideas from the concept of 'exercised decision-space' - traditionally used to measure local level managers' exercise of authority over health system functions following decentralisation. Our main outcome measure was the degree of exercised authority - classified as 'low', 'medium' or 'high' - over four M&E domains (HIV data collection, collation, analysis, and use). We applied ordinal logistic regression to assess whether actor type (horizontal or vertical) was predictive of a higher degree of exercised authority, independent of management capacity (training and experience), and M&E knowledge.

RESULTS

Relative to vertical managers, horizontal managers had lower HIV M&E knowledge, were more likely to exercise a higher degree of authority over HIV data collation (OR 7.26; CI: 1.9, 27.4), and less likely to do so over HIV data use (OR 0.19; CI: 0.05, 0.84). A higher HIV M&E knowledge score was predictive of a higher exercised authority over HIV data use (OR 1.22; CI: 0.99, 1.49). There was no association between management capacity and degree of authority.

CONCLUSIONS

This study demonstrates a HIV M&E model that is neither fully vertical nor integrated. The HIV M&E is characterised by horizontal managers producing HIV information while vertical managers use it. This may undermine policies to strengthen integrated health system planning and management under the leadership of horizontal managers.

Schistosomiasis control and the health system in P.R. China

Over the last sixty years advances have been made in the control of schistosomiasis in P.R. China. There are, however, difficult challenges still to be met. This paper looks at the extent to which the health system offers a positive environment for the control of the disease. It starts by tracing three phases in schistosomiasis control: disease elimination strategy through snail control (1950s-early 1980s); morbidity control strategy based on chemotherapy (mid 1980s to 2003); integrated control strategy (2004+). Each one of these phases took place in distinct policy-making environments. The paper partly draws on these phases to set out five issues of disease control and discusses them in the context of the health system and its recent trends. These cover the policy-making process, intersectoral action for health, equity and access to health services, funding for public goods and externalities, and strengthening resource management and planning. These issues form the basis of an agenda for integrating research and capacity strengthening in the Chinese health system with a view to creating a more positive enabling environment for schistosomiasis control. In so doing it is important to emphasize the role and integrity of the public sector against its commercialization, the underlying value of equity, a systems wide perspective, and the role of advocacy.

Integrating prevention of mother-to-child HIV transmission programs to improve uptake: a systematic review

Background

We performed a systematic review to assess the effect of integrated perinatal prevention of mother-to-child transmission of HIV interventions compared to non- or partially integrated services on the uptake in low- and middle-income countries.

Methods

We searched for experimental, quasi-experimental and controlled observational studies in any language from 21 databases and grey literature sources.

Results

Out of 28 654 citations retrieved, five studies met our inclusion criteria. A cluster randomized controlled trial reported higher probability of nevirapine uptake at the labor wards implementing HIV testing and structured nevirapine adherence assessment (RRR 1.37, bootstrapped 95% CI, 1.04–1.77). A stepped wedge design study showed marked improvement in antiretroviral therapy (ART) enrolment (44.4% versus 25.3%, p<0.001) and initiation (32.9% versus 14.4%, p<0.001) in integrated care, but the median gestational age of ART initiation (27.1 versus 27.7 weeks, p = 0.4), ART duration (10.8 versus 10.0 weeks, p = 0.3) or 90 days ART retention (87.8% versus 91.3%, p = 0.3) did not differ significantly. A cohort study reported no significant difference either in the ART coverage (55% versus 48% versus 47%, p = 0.29) or eight weeks of ART duration before the delivery (50% versus 42% versus 52%; p = 0.96) between integrated, proximal and distal partially integrated care. Two before and after studies assessed the impact of integration on HIV testing uptake in antenatal care. The first study reported that significantly more women received information on PMTCT (92% versus 77%, p<0.001), were tested (76% versus 62%, p<0.001) and learned their HIV status (66% versus 55%, p<0.001) after integration. The second study also reported significant increase in HIV testing uptake after integration (98.8% versus 52.6%, p<0.001).

Conclusion

Limited, non-generalizable evidence supports the effectiveness of integrated PMTCT programs. More research measuring coverage and other relevant outcomes is urgently needed to inform the design of services delivering PMTCT programs.

Disease control and health systems in low- and middle-income countries: enhancing positive interrelation

There is a growing interest in improving the relationship between disease control programmes and the rest of the health system in low- and middle-income countries. This short study seeks to contribute to this movement by providing a multi-dimensional approach for policy-makers and researchers. It recognizes the different and often conflicting perspectives in health systems held by stakeholders. Two such perspectives are those of disease control programmes and health systems. Both are based on perceived health needs and put forward requirements on each other through resource demands and organizational needs. Failure to reconcile these perspectives can lead to health system fragmentation. This study proposes a framework to address the importance of mutual support across stakeholder perspectives, striving to understand and analyse the consequences of their reciprocal views. In doing this, the study stresses the importance of common understanding around health system values, the political interplay between stakeholders, the contextual setting and the need to integrate research and capacity development in this area.

Health workers at the core of the health system: framework and research issues

This paper presents a framework for the health system with health workers at the core. We review existing health-system frameworks and the role they assign to health workers. Earlier frameworks either do not include health workers as a central feature of system functioning or treat them as one among several components of equal importance. As every function of the health system is either undertaken by or mediated through the health worker, we place the health worker at the center of the health system. Our framework is useful for structuring research on the health workforce and for identifying health-worker research issues. We describe six research issues on the health workforce: metrics to measure the capacity of a health system to deliver healthcare; the contribution of public- vs. private-sector health workers in meeting healthcare needs and demands; the appropriate size, composition and distribution of the health workforce; approaches to achieving health-worker requirements; the adoption and adaption of treatments by health workers; and the training of health workers for horizontally vs. vertically structured health systems.

Health system determinants of infant, child and maternal mortality: A cross-sectional study of UN member countries

OBJECTIVE

Few studies have examined the link between health system strength and important public health outcomes across nations. We examined the association between health system indicators and mortality rates.

METHODS

We used mixed effects linear regression models to investigate the strength of association between outcome and explanatory variables, while accounting for geographic clustering of countries. We modelled infant mortality rate (IMR), child mortality rate (CMR), and maternal mortality rate (MMR) using 13 explanatory variables as outlined by the World Health Organization.

RESULTS

Significant protective health system determinants related to IMR included higher physician density (adjusted rate ratio [aRR] 0.81; 95% Confidence Interval [CI] 0.71-0.91), higher sustainable access to water and sanitation (aRR 0.85; 95% CI 0.78-0.93), and having a less corrupt government (aRR 0.57; 95% CI 0.40-0.80). Out-of-pocket expenditures on health (aRR 1.29; 95% CI 1.03-1.62) were a risk factor. The same four variables were significantly related to CMR after controlling for other variables. Protective determinants of MMR included access to water and sanitation (aRR 0.88; 95% CI 0.82-0.94), having a less corrupt government (aRR 0.49; 95%; CI 0.36-0.66), and higher total expenditures on health per capita (aRR 0.84; 95% CI 0.77-0.92). Higher fertility rates (aRR 2.85; 95% CI: 2.02-4.00) were found to be a significant risk factor for MMR.

CONCLUSION

Several key measures of a health system predict mortality in infants, children, and maternal mortality rates at the national level. Improving access to water and sanitation and reducing corruption within the health sector should become priorities.

Neglected tropical disease (NTD) control in health systems: the interface between programmes and general health services

Disease control programmes are an intrinsic part of health systems. Neglected tropical disease (NTD) control is a clear case in point. While there is a growing consensus that NTD control and health services are linked, with important mutual impacts, little is known of what actually happens at the interface between the two entities. Here, we review the rationale, viewpoints and experiences of NTD control programmes regarding general health services, and vice versa, and compare their respective arguments. We discuss the interactions and interface between disease control and health systems, and present possible scenarios for health system strengthening by NTD- and other disease-specific programmes. Focusing on countries in sub-Saharan Africa, we suggest a number of principles that could pave the way for fruitful discussions and development of synergies.

Impact of measles elimination activities on immunization services and health systems: findings from six countries

BACKGROUND

One of the key concerns in determining the appropriateness of establishing a measles eradication goal is its potential impact on routine immunization services and the overall health system. The objective of this study was to evaluate the impact of accelerated measles elimination activities (AMEAs) on immunization services and health systems in 6 countries: Bangladesh, Brazil, Cameroon, Ethiopia, Tajikistan, and Vietnam.

METHODS

Primary data were collected from key informant interviews and staff profiling surveys. Secondary data were collected from policy documents, studies, and reports. Data analysis used qualitative approaches.

RESULTS

This study found that the impact of AMEAs varied, with positive and negative implications in specific immunization and health system functions. On balance, the impacts on immunization services were largely positive in Bangladesh, Brazil, Tajikistan, and Vietnam, while negative impacts were more significant in Cameroon and Ethiopia.

CONCLUSIONS

We conclude that while weaker health systems may not be able to benefit sufficiently from AMEAs, in more developed health systems, disruptions to health service delivery are unlikely to occur. Opportunities to strengthen the routine immunization service and health system should be actively sought to address system bottlenecks in order to incur benefits to eradication program itself as well as other health priorities.

Strategies for integrating primary health services in low- and middle-income countries at the point of delivery

BACKGROUND

In some low- and middle-income countries, separate vertical programmes deliver specific life-saving interventions but can fragment services. Strategies to integrate services aim to bring together inputs, organisation, and delivery of particular functions to increase efficiency and people's access. We examined the evidence on the effectiveness of integration strategies at the point of delivery (sometimes termed 'linkages'), including integrated delivery of tuberculosis (TB), HIV/AIDS and reproductive health programmes.

OBJECTIVES

To assess the effects of strategies to integrate primary health care services on healthcare delivery and health status in low- and middle-income countries.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 3, part of the The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care Group Specialised Register (searched 15 September  2010); MEDLINE, Ovid (1950 to August Week 5 2010) (searched 10 September  2010); EMBASE, Ovid (1980 to 2010 Week 35) (searched 10 September  2010); CINAHL, EBSCO (1980 to present) (searched 20 September 2010); Sociological Abstracts, CSA Illumina (1952 to current) (searched 10 September  2010); Social Services Abstracts, CSA Illumina (1979 to current) (searched 10 September  2010); POPLINE (1970 to current) (searched 10 September  2010); International Bibliography of the Social Sciences, Webspirs (1951 to current) (searched 01 July 2008); HealthStar (1975 to September 2005), Cab Health (1972 to 1999), and reference lists of articles. We also searched the World Health Organization (WHOLIS) library database, handsearched relevant WHO publications, and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials, non-randomised controlled trials, controlled before and after studies, and interrupted time series analyses of integration strategies, including strengthening linkages, in primary health care services. Health services in high-income countries, private public partnerships, and hospital inpatient care were excluded as were programmes promoting the integrated management of childhood illnesses. The main outcomes were indicators of healthcare delivery, user views, and health status.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed the risk of bias. The statistical results of individual studies are reported and summarised.

MAIN RESULTS

Five randomised trials and four controlled before and after studies were included. The interventions were complex.Five studies added an additional component, or linked a new component, to an existing service, for example, adding family planning or HIV counselling and testing to routine services. The evidence from these studies indicated that adding on services probably increases service utilisation but probably does not improve health status outcomes, such as incident pregnancies.Four studies compared integrated services to single, special services. Based on the included studies, fully integrating sexually transmitted infection (STI) and family planning, and maternal and child health services into routine care as opposed to delivering them as special 'vertical' services may decrease utilisation, client knowledge of and satisfaction with the services and may not result in any difference in health outcomes, such as child survival. Integrating HIV prevention and control at facility and community level improved the effectiveness of certain services (STI treatment in males) but resulted in no difference in health seeking behaviour, STI incidence, or HIV incidence in the population.

AUTHORS' CONCLUSIONS

There is some evidence that 'adding on' services (or linkages) may improve the utilisation and outputs of healthcare delivery. However, there is no evidence to date that a fuller form of integration improves healthcare delivery or health status. Available evidence suggests that full integration probably decreases the knowledge and utilisation of specific services and may not result in any improvements in health status. More rigorous studies of different strategies to promote integration over a wider range of services and settings are needed. These studies should include economic evaluation and the views of clients as clients' views will influence the uptake of integration strategies at the point of delivery and the effectiveness on community health of these strategies.

Integrating prevention of mother-to-child HIV transmission (PMTCT) programmes with other health services for preventing HIV infection and improving HIV outcomes in developing countries

BACKGROUND

Every year nearly 400,000 children are infected with HIV through mother-to-child transmission (MTCT), which is responsible for more than 90% of HIV infections in children. In high-income countries, the MTCT rate is less than 1% through perinatal prevention of mother-to-child HIV transmission (PMTCT) interventions. In low- and middle-income countries, PMTCT programme coverage remains low and consequently transmission rate high. The World Health Organisation recommends integration of PMTCT programmes with other healthcare services to increase access and improve uptake of these interventions.

OBJECTIVES

To assess the effect of integration of perinatal PMTCT measures with other health care services on coverage and service uptake compared to stand-alone PMTCT programmes and healthcare services or partially integrated PMTCT interventions.

SEARCH STRATEGY

We searched the following databases, for the time period of January 1990 to August 2010: MEDLINE, EMBASE, the WHO Global Health Library, CAB abstracts, CINAHL, POPLINE, PsycINFO, Sociological Abstracts, ERIC, AEGIS, Google Scholar, New York Academy of Medicine Grey Literature, Open SIGLE, British Library Catalogue, ProQuest Dissertation & Theses Database and U.S. National Library of Medicine Gateway system. We also searched the Cochrane Database of Systematic Reviews (the Cochrane Library 2010, Issue 7), the Cochrane Central Register of Controlled Trials (the Cochrane Library 2010, Issue 7), Database of Abstracts of Reviews on Effects (the Cochrane Library 2010, Issue 7). We also searched for ongoing trials in the WHO International Clinical Trials Registry and Controlled clinical trials (January 1990 to July 2010). We performed ISI Web of Knowledge Cited Reference Search and scanned the reference lists of the included articles for additional relevant studies. We contacted authors to locate additional eligible studies. To maximise sensitivity we did not employ any methodological filters.

SELECTION CRITERIA

Randomised controlled trials (RCT), cluster-randomised controlled trials (cluster RCT), controlled clinical trials (CCT), controlled before and after (CBA) studies and interrupted time series (ITS) studies comparing integrated PMTCT interventions to non-integrated or partially integrated care for pregnant women, mothers and their infants in low- and middle-income countries.

DATA COLLECTION AND ANALYSIS

Two review authors independently ran the searches, selected studies, assessed methodological quality, and extracted data. The third review author resolved any disagreements.

MAIN RESULTS

Only one study met the inclusion criteria. A cluster-randomised trial (12 clusters, n=7664), compared mother-infant nevirapine coverage at labour ward between intervention clinics implementing rapid HIV testing with structured nevirapine assessment and control clinics implementing informal assessment of nevirapine adherence. The authors measured nevirapine coverage in all clinics at baseline and after the implementation of the intervention. An increase of 10% (range of difference in coverage from -10% to +33%) was observed in the intervention sites compared to 10% decline in mother-infant coverage in the control sites (range of difference in coverage from -13% to 0%). The study showed that the probability of nevirapine coverage of mothers and their infants in the intervention arm compared to control arm increased from 0.89 at baseline to 1.22 during the intervention period, representing a multiplicative effect of 1.37 upon the ratio of relative risks at baseline (RR 1.37, bootstrapped 95% CI, 1.041.77). The study had a low risk of bias. No studies were found that evaluated the effectiveness of integrating other perinatal PMTCT interventions with healthcare services.

AUTHORS' CONCLUSIONS

We found only one study suggesting that integrating perinatal PMTCT interventions with other healthcare services in low- and middle-income countries increases the proportion of pregnant women, mothers and infants receiving PMTCT intervention. The weak evidence base does not enable making any inferences for other countries or contexts. The study that met the inclusion criteria assessed only the impact of integrating PMTCT intervention in labour ward on the proportion of mothers and their infants receiving nevirapine. The study showed significant improvement in intervention coverage but it only addressed the labour ward aspect of PMTCT programme. We did not find sufficient evidence to make definitive conclusions about the effectiveness of integration of these interventions with other health services rather than providing them as stand-alone services. Further research is urgently needed to assess the effect of integrating perinatal prevention of mother-to-child HIV transmission interventions with other health services on intervention coverage, service uptake, quality of care and health outcomes and the optimal integration modality.

Implementing antiretroviral therapy programs in resource-constrained settings: lessons from Monze, Zambia

We describe the impact of an antiretroviral therapy program on human resource utilization and service delivery in a rural hospital in Monze, Zambia, using qualitative data. We assess project impact on staff capacity utilization, service delivery, and community perception of care. Increased workload resulted in fatigue, low staff morale, and exacerbated critical manpower shortages, but also an increase in users of antiretroviral therapy, improvement in hospital infrastructure and funding, and an overall community satisfaction with service delivery. Integrating HAART programs within existing hospital units and services may be a good alternative to increase overall efficiency.

How to (or not to) integrate vertical programmes for the control of major neglected tropical diseases in sub-Saharan Africa

Combining the delivery of multiple health interventions has the potential to minimize costs and expand intervention coverage. Integration of mass drug administration is therefore being encouraged for delivery of preventive chemotherapy (PCT) to control onchocerciasis, lymphatic filariasis, schistosomiasis, soil-transmitted helminthiasis, and trachoma in sub-Saharan Africa, as there is considerable geographical overlap of these neglected tropical diseases (NTDs). With only a handful of countries having embarked on integrated NTD control, experience on how to develop and implement an efficient integrated programme is limited. Historically, national and global programmes were focused on the control of only one disease, usually through a comprehensive approach that involved several interventions including PCT. Overcoming the resulting disease-specific structures and thinking, and ensuring that the integrated programme is embedded within the existing health structures, pose considerable challenges to policy makers and implementers wishing to embark on integrated NTD control. By sharing experiences from Uganda, Tanzania, Southern Sudan, and Mozambique, this symposium article aims to outlines key challenges and solutions to assist countries in establishing efficient integrated NTD programmes.

Erratum to "Maternal, neonatal and child health interventions and services: moving from knowledge of what works to systems that deliver" [International Health 2 (2010) 87-98]

The Publisher regrets that an error occurred in the name of the 6th listed co-author for this paper. B. Matthias was listed in the original paper instead of M. Borchert; the correct listing can be seen above.

Optimising the use of routine immunisation clinics for early childhood development in sub-Saharan Africa

There is now ample evidence that factors that account for high infant and child mortality in sub-Saharan Africa and other developing regions are also associated with lifelong developmental impairments in the survivors from early childhood. Of all routine immunisation programmes widely administered soon after birth, bacille Calmette-Guérin (BCG) and diphtheria-pertussis-tetanus (DPT) offer effective platforms to implement a package of interventions that extend beyond child survival to include the early detection and prompt management of developmental disabilities as recently demonstrated in some pilot programmes in sub-Saharan Africa. This paradigm shift is consistent with the Global Immunisation Vision and Strategy (GIVS) of UNICEF/WHO for integrated interventions. It also accords with the current early childhood development policies of all major UN organisations and the World Bank. Such integrated programmes should now be widely encouraged throughout the region by its developmental partners.

Investment in HIV/AIDS programs: does it help strengthen health systems in developing countries?

BACKGROUND

There is increasing debate about whether the scaled-up investment in HIV/AIDS programs is strengthening or weakening the fragile health systems of many developing countries. This article examines and assesses the evidence and proposes ways forward.

DISCUSSION

Considerably increased resources have been brought into countries for HIV/AIDS programs by major Global Health Initiatives. Among the positive impacts are the increased awareness of and priority given to public health by governments. In addition, services to people living with HIV/AIDS have rapidly expanded. In many countries infrastructure and laboratories have been strengthened, and in some, primary health care services have been improved. The effect of AIDS on the health work force has been lessened by the provision of antiretroviral treatment to HIV-infected health care workers, by training, and, to an extent, by task-shifting. However, there are reports of concerns, too - among them, a temporal association between increasing AIDS funding and stagnant reproductive health funding, and accusations that scarce personnel are siphoned off from other health care services by offers of better-paying jobs in HIV/AIDS programs. Unfortunately, there is limited hard evidence of these health system impacts. Because service delivery for AIDS has not yet reached a level that could conceivably be considered "as close to Universal Access as possible," countries and development partners must maintain the momentum of investment in HIV/AIDS programs. At the same time, it should be recognized that global action for health is even more underfunded than is the response to the HIV epidemic. The real issue is therefore not whether to fund AIDS or health systems, but how to increase funding for both.

SUMMARY

The evidence is mixed - mostly positive but some negative - as to the impact on health systems of the scaled-up responses to HIV/AIDS driven primarily by global health partnerships. Current scaled-up responses to HIV/AIDS must be maintained and strengthened. Instead of endless debate about the comparative advantages of vertical and horizontal approaches, partners should focus on the best ways for investments in response to HIV to also broadly strengthen the primary health care systems.

Using immunization delivery strategies to accelerate progress in Africa towards achieving the Millennium Development Goals

Integration of health services brings together common functions within and between organizations to solve common problems, developing a commitment to a shared vision and goals, and using common technologies and resources to achieve these goals. Integration has been the frustrated rally call of Primary Health Care for 30 years. This paper discusses the process of integrating child survival strategies and other heath services with immunization in Africa. Immunization is arguably the most successful health programme throughout the continent, making it the logical vehicle for add-on services. Strong health systems are the best way of delivering cost-effective child survival interventions in a most sustainable manner. But the reality in many African countries is that health systems have been weak for a number of reasons. Joining additional cost-effective child survival interventions on to immunization services may provide the needed boost. The unacceptably high childhood mortality in parts of Africa makes it the ideal location to undertake this exercise. The urgency to scale-up child survival interventions that have proven cost-effective is especially important if the Millennium Development Goals (MDGs) are to be met by 2015. Africa has more to loose than most in failing to scale up to meet these goals, bearing as it does the highest burden of childhood mortality in the world. But so far, prospects do not look good for achieving MDG-4 for the countries with the highest mortality rates. The timeliness of this initiative towards integration could not be better. In the last five years, countries in Africa have received massive injections of financial resources for polio eradication and measles control as well as additional funding for a range of immunization-strengthening activities and the introduction of new and under-utilized vaccines. While the data to support integration are limited, the information to hand suggests the effectiveness of the strategy. Where immunization performance is strong, immunization contacts may be excellent vehicles for additional interventions such as de-worming or Integrated Management of Childhood Illness (IMCI). But where an immunization service is struggling, adding another child survival intervention on to immunization might be the straw that breaks its back. Health managers have a wide range of options for adding on to immunization services, but the best choice will depend very much on local situations.

Expanding access to antiretroviral therapy in sub-saharan Africa: avoiding the pitfalls and dangers, capitalizing on the opportunities

We describe a number of pitfalls that may occur with the push to rapidly expand access to antiretroviral therapy in sub-Saharan Africa. These include undesirable opportunity costs, the fragmentation of health systems, worsening health care inequities, and poor and unsustained treatment outcomes. On the other hand, AIDS "treatment activism" provides an opportunity to catalyze comprehensive health systems development and reduce health care inequities.However, these positive benefits will only happen if we explicitly set out to achieve them. We call for a greater commitment toward health activism that tackles the broader political and economic constraints to human and health systems development in Africa, as well as toward the resuscitation of inclusive and equitable public health systems.

A framework for analysing the relationship between disease control programmes and basic health care

In this paper, we present a framework for analysing the complex relationship between disease control programmes and basic health care systems. Many of the ideas and concepts presented in this paper were developed by the staff of the Public Health Department of the Antwerp Institute of Tropical Medicine (ITM) over the last 20 years. They are thus the product of the reflection of an entire team.

A code of best practice for disease control programmes to avoid damaging health care services in developing countries

How should we implement disease control programmes so as to strengthen existing health systems? To answer this question, we re-examined the integration of these programmes from a managerial perspective. Based on a literature review, we concluded that integration is essential in the majority of cases. We went on to examine the mechanisms whereby the integration of disease control activities can jeopardize health care delivery, resulting in low service utilization, low detection and cure rates, and patient delays. To do this we clustered disease control programmes into three categories and assessed the impact of each on local health care facilities. From these results, we suggest a series of measures designed to help aid agencies and national governments support local health care infrastructures or, as a minimum, avoid damaging them. Whilst some vertical programmes should never be integrated, two conditions are essential to the integration of others: (1) Disease control needs to be integrated with general health care delivery--which implies the possibility to deliver general practice/family medicine care in publicly oriented health services. (2) Integration of both operational and administrative aspects should take place simultaneously. Any health policies in developing countries tending to allocate disease control programmes to government facilities and general health care to private facilities preclude their integration. They risk unravelling the fabric on which both disease control and health care delivery depend.

The use of mass campaigns in the expanded program on immunization: a review of reported advantages and disadvantages

The use of mass immunization campaigns (MICs) has been and remains controversial. To evaluate these campaigns, the authors review the literature relating to their effectiveness, sustainability, and cost-effectiveness in controlling diseases and raising immunization coverage levels, and their impact on the subsequent development of routine immunization services. Well-conducted campaigns have increased vaccine coverage levels and decreased disease morbidity and mortality. Their use in the Americas has been associated with the apparent elimination of poliomyelitis. However, unless health care infrastructure is improved, or campaigns are repeated, gains in coverage levels may not be sustained. Studies suggest that MICs are often not as cost-effective for raising coverage as the delivery of vaccines through routine services, but the use of coverage as the only outcome measure is questionable. Mass immunization campaigns can increase awareness of vaccination and may be appropriate in situations where new programs are to be initiated, in refugee situations where people congregate into areas with little infrastructure, and in disease eradication efforts when specific time goals are set. Little information is available on whether MICs strengthen or interfere with the development of routine services. To be successful, MICs require a well-coordinated and planned effort on the part of national authorities with the identification of specific goals, intensive social promotion, and strong management. In addition, research is needed to clarify how MICs should be evaluated.

Is malaria control a priority? Evidence from Nepal

The research reported here assessed the value of malaria control through a cost-effectiveness study of the vertically-organized malaria control programme in Nepal. It presents a methodological framework for analysing cost-effectiveness which includes resource-saving consequences as well as health consequences. The methods used to collect data on control costs, cases and deaths prevented, treatment costs averted and production gains are described and the assumptions required by the analysis are made explicit. A variety of cost-effectiveness ratios are calculated, sensitivity analysis applied and the policy implications of the results considered. The results from Nepal are compared to estimates for parasitic disease and other health programmes in other countries: it is concluded that the Nepalese programme appears no less cost-effective than many other health interventions. It can also be justified by reference to the population groups benefiting from malaria control.

Community participation in disease control

The main determinants of community participation in disease control programmes are identified and a framework with eleven variables is developed. Attention is drawn to the political background, community characteristics, the managerial capacity of the provider and the epidemiology of the disease. The framework is designed to guide health professionals in the systematic assessment and monitoring of participation in disease control programmes. Analysis of the Ghanaian Guinea Worm Eradication Programme and the Nicaraguan Tuberculosis Control Programme are presented as case studies. They show that political support does not guarantee community participation in disease control programmes and stress the importance of other determinants such as commitment to PHC, intersectoral coordination, the project approach and human resources. The relevance of the epidemiology of the disease in determining what degree of community participation will be most effective is highlighted by the case studies.

The economic evaluation of malaria control technologies: the case of Nepal

This paper illustrates the methodological issues arising from the use of economic evaluation in a developing country context, and how economic evaluation can be applied in developing countries to draw conclusions of relevance to policy-makers. The paper reports research on the cost-effectiveness of the malaria control programme in Nepal. It outlines the heirarchy of choices presented by malaria control and concentrates on the evaluation of the mix of routine strategies employed by the programme, particularly for vector control and case detection and treatment. A social perspective is taken, and emphasis placed on identifying costs falling on households, namely private expenditure on treatment and loss of days of work. Conclusions are drawn relating to the application of economic evaluation methodology to disease control programmes in developing countries.

The development of the Essential Drugs Program and implications for self-reliance in Tanzania

This report provides a background history of the Essential Drugs Program (EDP) in Tanzania. Because of a scarcity of drugs in the Ministry of Health (MOH) managed units a program to fill up the empty shelves was welcomed. Critical questions were not addressed about other important policy components. Success of the EDP has been measured in terms of a successful delivery of drugs without questioning the source and its reliability in the near future. Other program components have not been implemented successfully to insure the program's substainability and self-reliance. There is a need to improve local production, quality assurance capability, inspection, intersectoral linkages and active local participation in shouldering the financial burden.