Developing AIDS care in Zimbabwe: a case for residential community centres?

The political economy of health financing reforms in Zimbabwe: a scoping review

Background

Implementation of health financing reforms for Universal Health Coverage (UHC) is inherently political. Despite the political determinants of UHC, health financing reform in Zimbabwe is often portrayed as a technical exercise with a familiar path of a thorough diagnosis of technical gaps followed by detailed prescriptions of reform priorities. In this study, we sought to understand the interaction between political and economic aspects of health financing reforms since the country got its independence in 1980.

Methods

We conducted a scoping review of health financing reforms in Zimbabwe and reviewed 84 relevant sources of information. We then conducted a thematic analysis using an adapted Fox and Reich’s framework of ideas and ideologies, interests and institutions.

Results

We found that ideas, institutions and interests significantly influence health financing reforms in Zimbabwe with implications on health system performance. Reform priorities of the 1980s were influenced by socialist ideologies with an interest to address pervasive health inequities inherited from the colonial racial system. The progress in equity realized in the 1980s was severely disrupted from the 1990s partly due to neo-liberal ideologies which steered interests towards market-oriented reforms. The period from the 2000s is characterized by increasing donor influence on health financing and a cumulative socio-economic collapse that resulted in a sharp and protracted decline in health spending and widening of health inequities.

Conclusion

Health financing reform process in Zimbabwe is heavily influenced by political economy characteristics which favor certain financing arrangements over others with profound implications on health system performance. We concluded that the political economy factors that slow down UHC reforms are not rooted in the ambiguities of ideas on what needs to be done. Instead, the missing link is how to move from intention to action by aligning espoused ideas with interests and institutions which is an inherently political and redistributive process. International and domestic actors involved in UHC in Zimbabwe  need to explicitly consider the politics of health financing reforms to improve the implementation feasibility of desired reforms.

Burden of Care among Caregivers of Persons Living with HIV/AIDS in Rural Namibia: Correlates and Outcomes

This study examined the correlates of burden of caregivers providing care to people living with HIV/AIDS in rural northern Namibia and the consequences of caregivers' burden on their physical health and mental health. A purposive sampling method was used to recruit a total of 97 primary caregivers (N = 97) in rural Namibia. We found that hunger and HIV stigma were both positively associated with caregiver burden. Caregiver burden was positively related to depression and negatively related to quality of life. The findings underscore the complex relationships between food insecurity and HIV stigma on caregiver burden and the outcomes of burden on quality of life and depressive symptoms. Policy and practice implications are also discussed.

How Much Should We Expect? Family Caregiving of AIDS Patients in Rural Uganda

The aim of this study was to measure the burden of care for family caregivers of AIDS patients. A cross-sectional exploratory design was used to describe the care experiences of family caregivers of AIDS care recipients. A questionnaire was used to interview 120 family caregivers of AIDS patients from four rural areas in western Uganda. The questions asked were related to 12 domains of family caregiving. Care burden scores of caregivers were calculated. It was found that care burden scores were high in all domains except those regarding relationships within the families and substance abuse. Serious work overload and low health status were reported. The high burden of caregiving puts family caregivers at risk for decreased health status and increased social isolation and depression.

Development and pilot evaluation of a home-based palliative care training and support package for young children in southern Africa

Background

The leading cause of death among young children in southern Africa is complications due to HIV infection and, in South Africa, over a third of all deaths of children younger than five are associated with HIV infection. There is a great and urgent need for children’s palliative care in Africa, whether HIV-related or not. It is often not possible for sick children and their carers to attend clinics and hospitals cannot accommodate children for long periods of time. As a result children are often cared for in their own homes where caregivers require support to provide informed and sensitive care to reduce children’s suffering. Home-care places a heavy burden on families, communities and home- and community-based care workers.

Methods

This project involved the development and pilot evaluation of a training and support package to guide home and community-based care workers to help caregivers of seriously ill young children at home in southern Africa. A number of research methods were used, including a cross-sectional survey of content experts using the Delphi technique, participatory action research with photo elicitation and qualitative thematic analysis.

Results

Because the palliative care needs of these children are complex, the package focuses on delivering 9 key messages essential to improving the quality of care provided for young children. Once the key messages were developed, culturally relevant stories were constructed to enhance the understanding, retention and enactment of the messages. The various research methods used, including literature reviews, the Delphi technique and photo-elicitation ensured that the content included in the package was medically sound and culturally relevant, acceptable, feasible, and comprehensive. The end product is a home-based paediatric palliative care training and support package in English designed to help train community workers who are in a position to support families to care for very sick young children at home as well as to support families in looking after a very sick child.

Conclusion

A pilot study to assess the training and support package found it to be useful in delivering the key messages to caregivers. The training component was found to be feasible. It is concluded that the package offers a practical means of integrating palliative care with home-based care. Further implementation and evaluation is needed to establish its utility and impact.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-016-0114-7) contains supplementary material, which is available to authorized users.

HIV service delivery models towards 'Zero AIDS-related Deaths': a collaborative case study of 6 Asia and Pacific countries

BACKGROUND

In the Asia-Pacific region, limited systematic assessment has been conducted on HIV service delivery models. Applying an analytical framework of the continuum of prevention and care, this study aimed to assess HIV service deliveries in six Asia and Pacific countries from the perspective of service availability, linking approaches and performance monitoring for maximizing HIV case detection and retention.

METHODS

Each country formed a review team that provided published and unpublished information from the national HIV program. Four types of continuum were examined: (i) service linkages between key population outreach and HIV diagnosis (vertical-community continuum); (ii) chronic care provision across HIV diagnosis and treatment (chronological continuum); (iii) linkages between HIV and other health services (horizontal continuum); and (iv) comprehensive care sites coordinating care provision (hub and heart of continuum).

RESULTS

Regarding the vertical-community continuum, all districts had voluntary counselling and testing (VCT) in all countries except for Myanmar and Vietnam. In these two countries, limited VCT availability was a constraint for referring key populations reached. All countries monitored HIV testing coverage among key populations. Concerning the chronological continuum, the proportion of districts/townships having antiretroviral treatment (ART) was less than 70% except in Thailand, posing a barrier for accessing pre-ART/ART care. Mechanisms for providing chronic care and monitoring retention were less developed for VCT/pre-ART process compared to ART process in all countries. On the horizontal continuum, the availability of HIV testing for tuberculosis patients and pregnant women was limited and there were sub-optimal linkages between tuberculosis, antenatal care and HIV services except for Cambodia and Thailand. These two countries indicated higher HIV testing coverage than other countries. Regarding hub and heart of continuum, all countries had comprehensive care sites with different degrees of community involvement.

CONCLUSIONS

The analytical framework was useful to identify similarities and considerable variations in service availability and linking approaches across the countries. The study findings would help each country critically adapt and adopt global recommendations on HIV service decentralization, linkages and integration. Especially, the findings would inform cross-fertilization among the countries and national HIV program reviews to determine county-specific measures for maximizing HIV case detection and retention.

Home-based care for people living with AIDS in Zimbabwe: voluntary caregivers' motivations and concerns

Similar to the healthcare systems of other resource-constrained countries with a high prevalence of HIV and AIDS, Zimbabwe's healthcare system encourages communities and non-governmental organisations (NGOs) to support the public healthcare sector by initiating home-based care activities and training volunteers to assist households in caring for individuals living with HIV. As part of the response, groups of volunteers were formed to provide basic material, social, nursing, and other kinds of support to members of AIDS-affected households. My research in Bulawayo, Zimbabwe, shows that motives for volunteering included: 1) religious values; 2) desire for prestige; 3) empathy derived from witnessing the suffering caused by AIDS illness; 4) hope of securing caregiving support in the future; 5) hope of enlarging one's network of those with access to political and economic power; and 6) hope of receiving material benefits in the future. This study further documents that volunteers' commitment to caregiving diminished between the early 1990s and 2009 due to: 1) the stigma of HIV and AIDS; 2) lack of funding, preventing volunteers from providing the needed care; 3) the large numbers of sick who are discharged from hospitals and clinics into home care; and 4) volunteers' 'burnout.' Strengthening volunteers' motivations for caregiving and addressing their concerns are crucial for providing effective care for individuals living with HIV or AIDS. In Zimbabwe, improvement of voluntary caregiving programmes requires better integration with the national healthcare system at the clinic level as well as collaboration with NGOs, community leaders and church groups, which have the potential to positively influence volunteers' commitment to caregiving.

The young, the rich, and the beautiful: Secrecy, suspicion and discourses of AIDS in the South African lowveld

This article investigates emic accounts of the AIDS deaths that have occurred in a village in the Bushbuckridge district of the South African lowveld. I argue that whilst AIDS was publicly hidden and shrouded in secrecy, private gossip created moral scripts about those suspected of having died of AIDS. Details of 47 AIDS deaths revealed that young women and relatively wealthy, sometimes powerful men were vulnerable to AIDS. I suggest that AIDS constitutes a moral crisis; peoples' sexual secrets and desires for commodities and sex featured prominently in local AIDS discourses. The article explores the similarity between AIDS and witchcraft as a metaphorical analogy. Both were highly secretive, and subjective, and circumstantial evidence identified witches and AIDS victims. AIDS and witchcraft were also concerned with the problem of unnatural and uncontrolled desire. The article explores these themes with regard to men and women's experiences respectively. Young 'beautiful women' who used sex to acquire wealth were said to 'buy their own coffins' (die of AIDS), yet relationships with wealthy men ensured household survival. Relatively affluent men were labelled incorrigible 'womanisers' who spread AIDS. Discourses of masculine sexuality focussed on men's lack of agency in sexual decision making. The article points to the tendency to ignore men's vulnerability and its implications for AIDS prevention.

A taxonomy for community-based care programs focused on HIV/AIDS prevention, treatment, and care in resource-poor settings

Community-based care (CBC) can increase access to key services for people affected by HIV/AIDS through the mobilization of community interests and resources and their integration with formal health structures. Yet, the lack of a systematic framework for analysis of CBC focused on HIV/AIDS impedes our ability to understand and study CBC programs. We sought to develop taxonomy of CBC programs focused on HIV/AIDS in resource-limited settings in an effort to understand their key characteristics, uncover any gaps in programming, and highlight the potential roles they play. Our review aimed to systematically identify key CBC programs focused on HIV/AIDS in resource-limited settings. We used both bibliographic database searches (Medline, CINAHL, and EMBASE) for peer-reviewed literature and internet-based searches for gray literature. Our search terms were ‘HIV’ or ‘AIDS’ and ‘community-based care’ or ‘CBC’. Two co-authors developed a descriptive taxonomy through an iterative, inductive process using the retrieved program information. We identified 21 CBC programs useful for developing taxonomy. Extensive variation was observed within each of the nine categories identified: region, vision, characteristics of target populations, program scope, program operations, funding models, human resources, sustainability, and monitoring and evaluation strategies. While additional research may still be needed to identify the conditions that lead to overall program success, our findings can help to inform our understanding of the various aspects of CBC programs and inform potential logic models for CBC programming in the context of HIV/AIDS in resource-limited settings. Importantly, the findings of the present study can be used to develop sustainable HIV/AIDS-service delivery programs in regions with health resource shortages.

A new analytical framework of 'continuum of prevention and care' to maximize HIV case detection and retention in care in Vietnam

BACKGROUND

The global initiative 'Treatment 2.0' calls for expanding the evidence base of optimal HIV service delivery models to maximize HIV case detection and retention in care. However limited systematic assessment has been conducted in countries with concentrated HIV epidemic. We aimed to assess HIV service availability and service connectedness in Vietnam.

METHODS

We developed a new analytical framework of the continuum of prevention and care (COPC). Using the framework, we examined HIV service delivery in Vietnam. Specifically, we analyzed HIV service availability including geographical distribution and decentralization and service connectedness across multiple services and dimensions. We then identified system-related strengths and constraints in improving HIV case detection and retention in care. This was accomplished by reviewing related published and unpublished documents including existing service delivery data.

RESULTS

Identified strengths included: decentralized HIV outpatient clinics that offer comprehensive care at the district level particularly in high HIV burden provinces; functional chronic care management for antiretroviral treatment (ART) with the involvement of people living with HIV and the links to community- and home-based care; HIV testing and counseling integrated into tuberculosis and antenatal care services in districts supported by donor-funded projects, and extensive peer outreach networks that reduce barriers for the most-at-risk populations to access services. Constraints included: fragmented local coordination mechanisms for HIV-related health services; lack of systems to monitor the expansion of HIV outpatient clinics that offer comprehensive care; underdevelopment of pre-ART care; insufficient linkage from HIV testing and counseling to pre-ART care; inadequate access to HIV-related services in districts not supported by donor-funded projects particularly in middle and low burden provinces and in mountainous remote areas; and no systematic monitoring of referral services.

CONCLUSIONS

Our COPC analytical framework was instrumental in identifying system-related strengths and constraints that contribute to HIV case detection and retention in care. The national HIV program plans to strengthen provincial programming by re-defining various service linkages and accelerate the transition from project-based approach to integrated service delivery in line with the 'Treatment 2.0' initiative.

A systematic review of the experiences of caregivers in providing home-based care to persons with HIV/AIDS in Africa

OBJECTIVES

The broad objective of this review was to describe the experiences of caregivers of people living with HIV/AIDS, in home-based settings in Africa, including the challenges and difficulties of caring as well as the positive aspects.

INCLUSION CRITERIA

This review considered studies in which family members were the primary informal caregivers of the person living with HIV/AIDS (adults and children) in Africa as well as studies in which informal caregivers (volunteers) from the community provided home-based care to persons living with HIV/AIDS in Africa. The phenomena of interest were the experiences of caregivers' in delivering home-based care to people living with HIV/AIDS and the types of data included experiential accounts of caregivers.

SEARCH STRATEGY

The search strategy sought to find both published and unpublished studies and papers, limited to the English language. An initial limited search strategy of MEDLINE and CINAHL was undertaken to identify relevant keywords contained in the title, abstract and subject descriptors. Terms identified in this way and the synonyms used by respective databases were used in an extensive search of the literature. Reference lists and bibliographies of the articles chosen searched and unpublished abstracts were searched through NEXUS.

METHODOLOGICAL QUALITY

Each paper was assessed independently by two reviewers for methodological quality. The internal validity (quality) of research papers was assessed using the Joanna Briggs Institute's Qualitative Assessment and Review Instrument and the authenticity of opinion papers was assessed using the Joanna Briggs Institute's Narrative, Opinion, and Text Assessment and Review Instrument. There were no disagreements between the two reviewers and therefore a third reviewer was not required.

DATA EXTRACTION

Data were extracted from relevant studies using the JBI-QARI and the NOTARI data extraction tools Data that were extracted related to the population and country in which the study had taken place; the methods used in the study. The study findings that were extracted related to experiences in caring.

DATA SYNTHESIS

Data synthesis aimed to portray an accurate description and interpretation of the experiences of those caring for people living with HIV/AIDS in Africa.

RESULTS

A total of 32 papers were retrieved. Of these, 14 were included in the review with nine being qualitative research papers and the remaining five being opinion or text papers. Reasons for the 18 papers being excluded from the review, were because experiences of caregivers were not addressed (10 papers); the definition of caregiver did not fit the inclusion criteria (two papers); the concept "home-based care" was not addressed (one paper) and five papers were not from Africa. Of the nine papers that were critically appraised using the JBI-QARI critical appraisal tool, three were excluded because of poor or incomplete descriptions of the methodology. The findings of the remaining six papers were extracted and used in the metasynthesis. Burden of caring, challenges in caring, stigma and support were the main categories that arose from the data.

CONCLUSION

Providing home-based care in Africa for persons with HIV/AIDS is a challenging experience for their caregivers. These challenges and burdens of the caregivers may be lessened by formal or informal support structures or be aggravated by the stigma surrounding HIV/AIDS.

Family caregivers in rural Uganda: the hidden reality

We conducted 16 in-depth interviews with family caregivers of AIDS patients in three rural districts in western Uganda. They were selected from a client visitation list of the home-based care program for AIDS patients, based on volunteer participation. Family caregivers reported huge problems associated with providing the necessary psychological, social, and economic care. They also said that the physical and emotional demands of caregiving are overwhelming daily challenges. Most support to AIDS patients provided by family, friends, and the churches. The study highlights the great burden of caregivers, in sub-Saharan Africa who most often are elderly women and young girls. This study examine, the burden and related health issues of family caregivers, primarily women, for AIDS patients in Uganda. It was part of a broad research project using qualitative methods on family caregiving in the home environment in sub-Saharan Africa. As the requirements for family care giving are often overwhelming for women under the conditions as they exist in Uganda and in other developing countries, it constitutes a gender issue of great importance that has not been appreciated fully in the international literature. Family caregiving is also of international relevance, as HIV/AIDS is a global pandemic of previously unknown proportions. In many poor countries, family caregiving is the most common and often the only care that AIDS patients receive, because clinic-based care often is not available close to home or is not affordable. Therefore, family caregiver support programs to alleviate this burden are essential for all those countries where HIV/AIDS is prevalent. Family caregiver burden encompasses medical, social, and economic issues at the household level, which requires an interdisciplinary approach in order to fully understand and appreciate the different dimensions of the family caregiver burden and its negative impact on the lives of so many women in so many countries.

Palliative care in sub-Saharan Africa

Control of pain and symptoms and terminal care are necessary for quality HIV and cancer care in sub-Saharan Africa. However, what constitutes feasible, accessible, and effective palliative care, and how to develop such services, remains to be resolved. Africa-specific palliative care includes components that carry resource implications. Home and community-based care has been largely successful, but community capacity and the resources and clinical supervision necessary to sustain quality care are lacking. Coverage and referrals must be primary concerns. Simple lay and professional protocols have been developed, but opioid availability remains a major constraint. Areas of good practice, and areas where further success may be achieved include: attention to community needs and capacity; explicit frameworks for service development and palliative-care integration throughout the disease course (including antiretroviral provision); further education and protocols; strengthening and dissemination of diverse referral and care systems; increasing advocacy; and funding and technical skills to build audit and quality assessment.

Fosterage patterns in the age of AIDS: continuity and change

An estimated 4 million children, or about 10% of the entire South African population, will be orphaned by the year 2015. There is growing consensus that the extended family system is no longer capable of providing for orphans given severe economic constraints. There is, therefore, an urgency to develop appropriate interventions to support families and take care of these children. This article examines some of the existing literature on child fosterage and uses it to highlight understudied aspects of the current situation of children orphaned through AIDS in South Africa. Of particular concern are the points of continuity and change in fosterage patterns before and after the onset of the epidemic in South Africa. I suggest that an understanding of the short- and long-term consequences for children orphaned by AIDS in South Africa calls for historical contextualisation given that child fostering, both voluntarily and involuntarily, has been a feature of black family life since well before the onset of HIV/AIDS. In addition, I demonstrate the value of examining kinship, family, and networks in order to fully understand the circumstances of fostering these children. The paper concludes with a call for more research on children orphaned by AIDS in South Africa that will provide not only more data, but also enrich theoretical approaches to studying patterns of child fosterage in Africa and elsewhere.

Reducing social vulnerability to HIV/AIDS: models of care and their impact in resource-poor settings

There has been an increasing understanding of the social, economic, cultural and political factors that have shaped the HIV/AIDS epidemic. It has been widely recognized that in order to have effective prevention programmes for HIV/AIDS, the broader determinants of health must be addressed. Concurrently, a deeper understanding of personal and societal vulnerability to HIV/AIDS has emerged. Some prevention efforts have expanded their focus, addressing not only individual risk factors and behaviour, but also social justice and including community mobilization activities to address the wider context of the disease. However, the transition to an expanded approach to mitigating the effects of the HIV/AIDS epidemic has not been complete. There is little evidence that care and support strategies have systematically tried to address these concepts. While the role care plays in prevention is considered vital, viewing models of care in terms of their impact on the social vulnerability of certain groups to HIV/AIDS has been largely neglected. Yet appropriate care programmes that help reduce vulnerability will arguably also make the greatest contribution for prevention. Drawing on examples of the role social vulnerability has played in prevention efforts, this paper evaluates the impact of HIV/AIDS care models on socially vulnerable groups, such as women and children.