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Wichmann B, Moreira Wichmann R. Using machine learning to estimate health spillover effects. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2024; 25:717-730. [PMID: 37543994 DOI: 10.1007/s10198-023-01621-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 07/17/2023] [Indexed: 08/08/2023]
Abstract
We develop a nonparametric model to study health spillover effects of policy interventions. We use double/debiased machine learning to estimate the model using data from 74 hospitals in Rio de Janeiro, Brazil, and examine cross-patient spillover effects during the COVID-19 pandemic. The pandemic forced hospitals to develop new protocols to offer intensive care to both COVID and non-COVID patients. Our results show that the need to care for COVID patients affects health outcomes of non-COVID patients. Controlling for a number of confounders, we find that mortality rates and length of stay of non-COVID ICU patients increase when hospitals simultaneously offer intensive care to both types of patients. Policy simulations suggest that an increase in the number of ICU beds can counter morbidity spillover, but it is unlikely to be a feasible approach to counter mortality spillover.
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Affiliation(s)
- Bruno Wichmann
- Department of Resource Economics and Environmental Sociology, College of Natural and Applied Sciences, University of Alberta, 503 General Services Building, Edmonton, T6G-2H1, AB, Canada.
| | - Roberta Moreira Wichmann
- World Bank, SCES Trecho 03, Lote 05, Ed. Polo 8, S/N, Brasília, DF, CEP 70200-003, Brazil
- Brazilian Institute of Education, Development and Research IDP, Economics Graduate Program, SGAS Quadra 607 - Modulo 49 - Via L2 Sul, Brasília, DF, CEP 70.200-670, Brazil
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Zakumumpa H, Paina L, Ssegujja E, Shroff ZC, Namakula J, Ssengooba F. The impact of shifts in PEPFAR funding policy on HIV services in Eastern Uganda (2015-21). Health Policy Plan 2024; 39:i21-i32. [PMID: 38253438 PMCID: PMC10803197 DOI: 10.1093/heapol/czad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 09/19/2023] [Accepted: 10/20/2023] [Indexed: 01/24/2024] Open
Abstract
Although donor transitions from HIV programmes are increasingly common in low-and middle-income countries, there are limited analyses of long-term impacts on HIV services. We examined the impact of changes in President's Emergency Plan for AIDS Relief (PEPFAR) funding policy on HIV services in Eastern Uganda between 2015 and 2021.We conducted a qualitative case study of two districts in Eastern Uganda (Luuka and Bulambuli), which were affected by shifts in PEPFAR funding policy. In-depth interviews were conducted with PEPFAR officials at national and sub-national levels (n = 46) as well as with district health officers (n = 8). Data were collected between May and November 2017 (Round 1) and February and June 2022 (Round 2). We identified four significant donor policy transition milestones: (1) between 2015 and 2017, site-level support was withdrawn from 241 facilities following the categorization of case study districts as having a 'low HIV burden'. Following the implementation of this policy, participants perceived a decline in the quality of HIV services and more frequent commodity stock-outs. (2) From 2018 to 2020, HIV clinic managers in transitioned districts reported drastic drops in investments in HIV programming, resulting in increased patient attrition, declining viral load suppression rates and increased reports of patient deaths. (3) District officials reported a resumption of site-level PEPFAR support in October 2020 with stringent targets to reverse declines in HIV indicators. However, PEPFAR declared less HIV-specific funding. (4) In December 2021, district health officers reported shifts by PEPFAR of routing aid away from international to local implementing partner organizations. We found that, unlike districts that retained PEPFAR support, the transitioned districts (Luuka and Bulambuli) fell behind the rest of the country in implementing changes to the national HIV treatment guidelines adopted between 2017 and 2020. Our study highlights the heavy dependence on PEPFAR and the need for increasing domestic financial responsibility for the national HIV response.
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Affiliation(s)
- Henry Zakumumpa
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Ligia Paina
- Bloomberg School of Public Health, Johns Hopkins University, P O Box 7062, Kampala, Uganda
| | - Eric Ssegujja
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Zubin Cyrus Shroff
- Alliance for Health Policy and Systems, World Health Organization, 20 Avenue Appia, Geneva 1211, Switzerland
| | - Justin Namakula
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Freddie Ssengooba
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
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Yeo KH, Sathi KT, Acharya S, Yazdi Y. Navigating Breast Cancer Innovation in Uganda: Within and Without the Textbook. IEEE Pulse 2024; 15:15-19. [PMID: 38619929 DOI: 10.1109/mpuls.2024.3370450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
The Center for Bioengineering Innovation and Design (CBID) at Johns Hopkins University (JHU) has established a comprehensive approach to addressing global health challenges. Central to CBID's modality on global health is a strategy that integrates education, research, and collaboration. Through its graduate program, CBID trains the next generation of health care innovators to address the specific needs of low- and middle-income countries (LMICs). Graduate student teams at CBID begin their year with a focus on a health care thematic area associated with a target country.
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Fox A, Kim H. HIV policy legacies, pandemic preparedness and policy effort to address COVID-19. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001767. [PMID: 37363903 DOI: 10.1371/journal.pgph.0001767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 05/22/2023] [Indexed: 06/28/2023]
Abstract
That the world was unprepared for a major infectious disease outbreak is now readily apparent to all credible observers. However, some countries were more prepared than others and we have seen a variety of responses to COVID-19 emerge across nations. While recognizing that the sources of variation in country responses to COVID-19 are many and varied, in this study we seek to examine how policy legacies from national responses to HIV have influenced countries' responses to COVID-19. The aim of this study was to examine whether countries with a more conducive HIV policy environment were better prepared for COVID-19 and have therefore had more preemptive and rights-based responses. Using data from the Oxford Covid-19 Government Response Tracker, we develop measures of country effort to respond to COVID-19 including early containment and closure policies, prevention policies, economic policies, and health system policies. We combine this with data from the HIV Policy Lab and correlate overall and disaggregated country HIV Policy scores with COVID-19 Policy scores. We find that the COVID-19 Containment and Closure Measures Index was negatively correlated with supportive social policies related to HIV in the early stages of the pandemic, but the association did not persist as time went on. The COVID-19 Economic Support Measures had prolonged positive associations with supportive social policies related to HIV and negative association with clinical and treatment policies. Countries with stronger structural responses to HIV have been less inclined towards involuntary measures and more prepared for the social and economic elements of COVID-19 pandemic response.
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Affiliation(s)
- Ashley Fox
- Department of Public Administration and Policy, Rockefeller College of Public Affairs and Policy, University at Albany, Albany, NY, United States of America
| | - Heeun Kim
- Department of Public Administration and Policy, Rockefeller College of Public Affairs and Policy, University at Albany, Albany, NY, United States of America
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Trejo MJ, Soliman AS, Chen Y, Kalima M, Chuba A, Chama E, Mwaba CK, Banda L, Lishimpi K. Effects of HIV infection on metastatic cervical cancer and age at diagnosis among patients in Lusaka, Zambia. Int J Gynaecol Obstet 2022; 156:521-528. [PMID: 34121186 PMCID: PMC8669036 DOI: 10.1002/ijgo.13784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/12/2021] [Accepted: 06/11/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To examine the association between the duration of HIV infection and the stage of cervical cancer in Lusaka, Zambia. METHODS This retrospective case-case study included 1583 cervical cancer patients from the Cancer Diseases Hospital in Lusaka, Zambia. A sub-population of HIV-positive patients with additional clinical HIV information was identified following linkage of cancer and HIV databases. Logistic regression models examined the relationship between HIV status and early-onset cervical cancer diagnosis, and between HIV infection duration and initial diagnosis of metastatic cervical cancer. RESULTS The study population had an average age of 49 years and 40.9% had an initial diagnosis of metastatic cancer. HIV-positive women were more than twice as likely to be diagnosed at early-onset cervical cancer compared with HIV-negative women. Among the sub-population of HIV-positive patients, a longer duration of HIV infection was associated with 20% lowered odds of initial metastatic cancer diagnosis. CONCLUSION The availability, accessibility, and impact of the cervical screening program in this population should be further examined to elucidate the relationship between cervical screening, age, and duration of HIV infection and the the stage of diagnosis of cervical cancer.
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Affiliation(s)
- Mario Jesus Trejo
- Department of Epidemiology and Biostatistics, Mel & Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ, USA
| | - Amr S. Soliman
- Department of Community Health and Social Medicine, School of Medicine, The City College of New York, New York, NY, USA,Correspondence Amr S. Soliman, City University of New York School of Medicine, New York, NY, USA.
| | - Yuli Chen
- Department of Epidemiology, Colorado School of Public Health, University of Colorado
| | - Mulele Kalima
- University Teaching Hospital – HIV/AIDS Program, Lusaka, Zambia
| | - Alick Chuba
- University Teaching Hospital – HIV/AIDS Program, Lusaka, Zambia
| | - Eslone Chama
- University Teaching Hospital – HIV/AIDS Program, Lusaka, Zambia
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Müller P, Velez Lapão L. Mixed methods systematic review and metasummary about barriers and facilitators for the implementation of cotrimoxazole and isoniazid-Preventive therapies for people living with HIV. PLoS One 2022; 17:e0251612. [PMID: 35231047 PMCID: PMC8887777 DOI: 10.1371/journal.pone.0251612] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 02/10/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Cotrimoxazole and isoniazid preventive therapy (CPT, IPT) have been shown to be efficacious therapies for the prevention of opportunistic infections and tuberculosis (TB) among people living with human immunodeficiency virus (HIV). Despite governments' efforts to translate World Health Organization recommendations into practice, implementation remains challenging. This review aimed to explore and compare CPT and IPT with respect to similarities and differences of barriers identified across high TB/HIV burden countries. A secondary objective was to identify facilitators for implementing both preventive therapies. METHODS We searched MEDLINE, Web of Science and SCOPUS databases for peer-reviewed literature published before September 2020. We extracted and synthesized our findings using Maxqda software. We applied framework synthesis in conjunction with metasummary to compare both therapies with respect to similarities and differences of barriers identified across seven health system components (in line with the modified WHO's Framework for action). Protocol registration: PROSPERO (CRD42019137778). FINDINGS We identified four hundred and eighty-two papers, of which we included forty for review. Although most barrier themes were identical for both preventive therapies, we identified seven intervention-specific themes. Like for CPT, barriers identified for IPT were most frequently classified as 'service delivery-related barriers' and 'patient & community-related barriers'. 'Health provider-related barriers' played an important role for implementing IPT. Most facilitators identified referred to health system strengthening activities. CONCLUSIONS For researchers with limited working experience in high TB/HIV burden countries, this review can provide valuable insights about barriers that may arise at different levels of the health system. For policymakers in high TB/HIV burden countries, this review offers strategies for improving the delivery of IPT (or any newer therapy regimen) for the prevention of TB. Based on our findings, we suggest initial and continuous stakeholder involvement, focusing on the efficient use and reinforcement of existing resources for health.
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Affiliation(s)
- Pia Müller
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa (UNL), Lisboa, Portugal
| | - Luís Velez Lapão
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa (UNL), Lisboa, Portugal
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Hemingway CD, Bella Jalloh M, Silumbe R, Wurie H, Mtumbuka E, Nhiga S, Lusasi A, Pulford J. Pursuing health systems strengthening through disease-specific programme grants: experiences in Tanzania and Sierra Leone. BMJ Glob Health 2021; 6:bmjgh-2021-006615. [PMID: 34615662 PMCID: PMC8496380 DOI: 10.1136/bmjgh-2021-006615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/10/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction Disease-specific ‘vertical’ programmes and health system strengthening (HSS) ‘horizontal’ programmes are not mutually exclusive; programmes may be implemented with the dual objectives of achieving both disease-specific and broader HSS outcomes. However, there remains an ongoing need for research into how dual objective programmes are operationalised for optimum results. Methods A qualitative study encompassing four grantee programmes from two partner countries, Tanzania and Sierra Leone, in the Comic Relief and GlaxoSmithKline ‘Fighting Malaria, Improving Health’ partnership. Purposive sampling maximised variation in terms of geographical location, programme aims and activities, grantee type and operational sector. Data were collected via semi-structured interviews. Data analysis was informed by a general inductive approach. Results 51 interviews were conducted across the four grantees. Grantee organisations structured and operated their respective projects in a manner generally supportive of HSS objectives. This was revealed through commonalities identified across the four grantee organisations in terms of their respective approach to achieving their HSS objectives, and experienced tensions in pursuit of these objectives. Commonalities included: (1) using short-term funding for long-term initiatives; (2) benefits of being embedded in the local health system; (3) donor flexibility to enable grantee responsiveness; (4) the need for modest expectations; and (5) the importance of micro-innovation. Conclusion Health systems strengthening may be pursued through disease-specific programme grants; however, the respective practice of both the funder and grantee organisation appears to be a key influence on whether HSS will be realised as well as the overall extent of HSS possible.
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Affiliation(s)
| | - Mohamed Bella Jalloh
- University of Sierra Leone College of Medicine and Allied Health Sciences, Freetown, Sierra Leone.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Richard Silumbe
- Malaria Program, Clinton Health Access Initiative, Freetown, Sierra Leone
| | - Haja Wurie
- University of Sierra Leone College of Medicine and Allied Health Sciences, Freetown, Sierra Leone
| | | | - Samuel Nhiga
- National Malaria Control Program, Dodoma, Tanzania, United Republic of
| | - Abdallah Lusasi
- National Malaria Control Program, Dodoma, Tanzania, United Republic of
| | - Justin Pulford
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Zakumumpa H, Rujumba J, Amde W, Damian RS, Maniple E, Ssengooba F. Transitioning health workers from PEPFAR contracts to the Uganda government payroll. Health Policy Plan 2021; 36:1397-1407. [PMID: 34240177 PMCID: PMC8505860 DOI: 10.1093/heapol/czab077] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 05/28/2021] [Accepted: 06/25/2021] [Indexed: 11/14/2022] Open
Abstract
Although increasing public spending on health worker (HW) recruitments could reduce workforce shortages in sub-Saharan Africa, effective strategies for achieving this are still unclear. We aimed to understand the process of transitioning HWs from President's Emergency Plan for AIDS Relief (PEPFAR) to Government of Uganda (GoU) payrolls and to explore the facilitators and barriers encountered in increasing domestic financial responsibility for absorbing this expanded workforce. We conducted a multiple case study of 10 (out of 87) districts in Uganda which received PEPFAR support between 2013 and 2015 to expand their health workforce. We purposively selected eight districts with the highest absorption rates ('high absorbers') and two with the lowest absorption rates ('low absorbers'). A total of 66 interviews were conducted with high-level officials in three Ministries of Finance, Health and Public Service (n = 14), representatives of PEPFAR-implementing organizations (n = 16), district health teams (n = 15) and facility managers (n = 22). Twelve focus groups were conducted with 87 HWs absorbed on GoU payrolls. We utilized the Consolidated Framework for Implementation Research to guide thematic analysis. At the sub-national level, facilitators of transition in 'high absorber' districts were identified as the presence of transition 'champions', prioritizing HWs in district wage bill commitments, host facilities providing 'bridge financing' to transition workforce during salary delays and receiving donor technical support in district wage bill analysis-attributes that were absent in 'low absorber' districts. At the national level, multi-sectoral engagements (incorporating the influential Ministry of Finance), developing a joint transition road map, aligning with GoU salary scales and recruitment processes emerged as facilitators of the transition process. Our case studies offer implementation research lessons on effective donor transition and insights into pragmatic strategies for increasing public spending on expanding the health workforce in a low-income setting.
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Affiliation(s)
- Henry Zakumumpa
- School of Public Health, University of the Western Cape, Private Bag x17, Bellville, 7535 Republic of South Africa
| | - Joseph Rujumba
- Makerere University, School of Medicine, P O Box 7062, Kampala, Uganda
| | - Woldekidan Amde
- School of Public Health, University of the Western Cape, Private Bag x17, Bellville, 7535 Republic of South Africa
| | | | - Everd Maniple
- School of Medicine, Kabale University, P O Box 317, Kabale, Uganda
| | - Freddie Ssengooba
- Makerere University, School of Public Health, P O Box 7072, Kampala, Uganda
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Zakumumpa H, Paina L, Wilhelm J, Ssengooba F, Ssegujja E, Mukuru M, Bennett S. The impact of loss of PEPFAR support on HIV services at health facilities in low-burden districts in Uganda. BMC Health Serv Res 2021; 21:302. [PMID: 33794880 PMCID: PMC8017884 DOI: 10.1186/s12913-021-06316-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 03/25/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Although donor transitions from HIV programs are more frequent, little research exists seeking to understand the perceptions of patients and providers on this process. Between 2015 and 2017, PEPFAR implemented the ´geographic prioritization´ (GP) policy in Uganda whereby it shifted support from 734 'low-volume' facilities and 10 districts with low HIV burden and intensified support in select facilities in high-burden districts. Our analysis intends to explore patient and provider perspectives on the impact of loss of PEPFAR support on HIV services in transitioned health facilities in Uganda. METHODS We report qualitative findings from a larger mixed-methods evaluation. Six facilities were purposefully selected as case studies seeking to ensure diversity in facility ownership, size, and geographic location. Five out of the six selected facilities had experienced transition. A total of 62 in-depth interviews were conducted in June 2017 (round 1) and November 2017 (round 2) with facility in-charges (n = 13), ART clinic managers (n = 12), representatives of PEPFAR implementing organizations (n = 14), district health managers (n = 23) and 12 patient focus group discussions (n = 72) to elicit perceived effects of transition on HIV service delivery. Data were analyzed using thematic analysis. RESULTS While core HIV services, such as testing and treatment, offered by case-study facilities prior to transition were sustained, patients and providers reported changes in the range of HIV services offered and a decline in the quality of HIV services offered post-transition. Specifically, in some facilities we found that specialized pediatric HIV services ceased, free HIV testing services stopped, nutrition support to HIV clients ended and the 'mentor mother' ART adherence support mechanism was discontinued. Patients at three ART-providing facilities reported that HIV service provision had become less patient-centred compared to the pre-transition period. Patients at some facilities perceived waiting times at clinics to have become longer, stock-outs of anti-retroviral medicines to have been more frequent and out-of-pocket expenditure to have increased post-transition. CONCLUSIONS Participants perceived transition to have had the effect of narrowing the scope and quality of HIV services offered by case-study facilities due to a reduction in HIV funding as well as the loss of the additional personnel previously hired by the PEPFAR implementing organizations for HIV programming. Replacing the HIV programming gap left by PEPFAR in transition districts with Uganda government services is critical to the attainment of 90-90-90 targets in Uganda.
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Affiliation(s)
- Henry Zakumumpa
- School of Public Health, Makerere University, Kampala, Uganda.
| | - Ligia Paina
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Jess Wilhelm
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | | | - Eric Ssegujja
- School of Public Health, Makerere University, Kampala, Uganda
| | - Moses Mukuru
- School of Public Health, Makerere University, Kampala, Uganda
| | - Sara Bennett
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
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Hung YW, Hoxha K, Irwin BR, Law MR, Grépin KA. Using routine health information data for research in low- and middle-income countries: a systematic review. BMC Health Serv Res 2020; 20:790. [PMID: 32843033 PMCID: PMC7446185 DOI: 10.1186/s12913-020-05660-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 08/16/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Routine health information systems (RHISs) support resource allocation and management decisions at all levels of the health system, as well as strategy development and policy-making in many low- and middle-income countries (LMICs). Although RHIS data represent a rich source of information, such data are currently underused for research purposes, largely due to concerns over data quality. Given that substantial investments have been made in strengthening RHISs in LMICs in recent years, and that there is a growing demand for more real-time data from researchers, this systematic review builds upon the existing literature to summarize the extent to which RHIS data have been used in peer-reviewed research publications. METHODS Using terms 'routine health information system', 'health information system', or 'health management information system' and a list of LMICs, four electronic peer-review literature databases were searched from inception to February 202,019: PubMed, Scopus, EMBASE, and EconLit. Articles were assessed for inclusion based on pre-determined eligibility criteria and study characteristics were extracted from included articles using a piloted data extraction form. RESULTS We identified 132 studies that met our inclusion criteria, originating in 37 different countries. Overall, the majority of the studies identified were from Sub-Saharan Africa and were published within the last 5 years. Malaria and maternal health were the most commonly studied health conditions, although a number of other health conditions and health services were also explored. CONCLUSIONS Our study identified an increasing use of RHIS data for research purposes, with many studies applying rigorous study designs and analytic methods to advance program evaluation, monitoring and assessing services, and epidemiological studies in LMICs. RHIS data represent an underused source of data and should be made more available and further embraced by the research community in LMIC health systems.
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Affiliation(s)
- Yuen W Hung
- University of Waterloo, School of Public Health and Health Systems, Waterloo, Canada
| | - Klesta Hoxha
- University of Waterloo, School of Public Health and Health Systems, Waterloo, Canada
| | - Bridget R Irwin
- Department of Health Sciences, Wilfrid Laurier University, Waterloo, Canada
| | - Michael R Law
- Centre for Health Services and Policy Research, The University of British Columbia, Vancouver, Canada
| | - Karen A Grépin
- School of Public Health, Hong Kong University, Pok Fu Lam, Hong Kong.
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Essue BM, Kapiriri L. Priority setting for health system strengthening in low income countries. A qualitative case study illustrating the complexities. Health Syst (Basingstoke) 2020; 10:222-237. [PMID: 34377445 DOI: 10.1080/20476965.2020.1758596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Health systems are critical to the realisation of Universal Health Coverage. There has been insufficient attention to the evaluation of priority setting for health system strengthening within low income countries, including evaluation of the local capacity to implement priorities. This study evaluated the extent to which health system strengthening was prioritized in Uganda. The Kapiriri & Martin framework was used to evaluate health system priority setting from 2005-2015. A document analysis was triangulated with interview data (n = 67) from global, national and subnational stakeholders and analysed using content analysis. Health system strengthening was perceived to be circumvented by a lack of resources as well as influential actors with disease focused, rather than system-oriented, interests. There were defined processes with explicit criteria for identifying priorities and evidence was highly valued. But sub-optimal transparency and weak accountability often compromised the integrity of priority setting and contributed to stalling progress on health system strengthening and achieving health system outcomes. The strengths in the current planning processes should be harnessed. In addition, a systematic approach to priority setting, potentially through the establishment of an independent body, and stronger oversight mechanisms, would strengthen health system planning in this setting.
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Affiliation(s)
- Beverley M Essue
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Lydia Kapiriri
- Department of Health, Aging and Society, McMaster University, Hamilton, ON, Canada
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The impact of PEPFAR transition on HIV service delivery at health facilities in Uganda. PLoS One 2019; 14:e0223426. [PMID: 31596884 PMCID: PMC6785126 DOI: 10.1371/journal.pone.0223426] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 09/20/2019] [Indexed: 12/03/2022] Open
Abstract
Background Since 2004, the President’s Emergency Plan for AIDS Relief (PEPFAR) has played a large role in Uganda’s HIV/AIDS response. To better target resources to high burden regions and facilities, PEPFAR planned to withdraw from 29% of previously-supported health facilities in Uganda between 2015 and 2017. Methods We conducted a cross-sectional survey of 226 PEPFAR-supported health facilities in Uganda in mid-2017. The survey gathered information on availability, perceived quality, and access to HIV services before and after transition. We compare responses for facilities transitioned to those maintained on PEPFAR, accounting for survey design. We also extracted data from DHIS2 for the period October 2013–December 2017 on the number of HIV tests and counseling (HTC), number of patients on antiretroviral therapy (Current on ART), and retention on first-line ART (Retention) at 12 months. Using mixed effect models, we compare trends in service volume around the transition period. Results There were 206 facilities that reported transition and 20 that reported maintenance on PEPFAR. Some facilities reporting transition may have been in a gap between implementing partners. The median transition date was September 2016, nine months prior to the survey. Transition facilities were more likely to discontinue HIV outreach following transition (51.6% vs. 1.4%, p<0.001) and to report declines in HIV care access (43.5% vs. 3.1%, p<0.001) and quality (35.6% vs. 0%, p<0.001). However, transition facilities did not differ in their trends in HIV service volume relative to maintenance facilities. Conclusions Transition from PEPFAR resulted in facilities reporting worsening patient access and service quality for HIV care, but there is insufficient evidence to suggest negative impacts on volume of HIV services. Facility respondents’ perceptions about access and quality may be overly pessimistic, or they may signal forthcoming impacts. Unrelated to transition, declining retention on ART in Uganda is a cause for concern.
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Barnhart DA, Tsikhutsu I, Kirui D, Sawe F, Muli J, Sugut W, Abboud N, Birx D, Hamm T, Coakley P, Hickey PW, Wolfman V, Lee E, Spiegelman D. Association of the US President's Emergency Plan for AIDS Relief's Funding With Prevention of Mother-to-Child Transmission of HIV in Kenya. JAMA Netw Open 2019; 2:e1911318. [PMID: 31517966 PMCID: PMC6745052 DOI: 10.1001/jamanetworkopen.2019.11318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE From 2004 to 2014, the US President's Emergency Plan for AIDS Relief (PEPFAR) invested more than $248 000 000 in the prevention of mother-to-child transmission (PMTCT) of HIV in Kenya. Concurrently, child mortality in Kenya decreased by half. OBJECTIVE To identify the extent to which the decrease in child mortality in Kenya is associated with PEPFAR funding for PMTCT of HIV. DESIGN, SETTING, AND PARTICIPANTS This population-based survey study conducted in Kenya estimated the association between annual per capita PEPFAR funding for PMTCT (annual PCF) and cumulative per capita PEPFAR funding for PMTCT (cumulative PCF), extracted using 2004-2014 country operational reports as well as individual-level health outcomes, extracted from the 2003, 2008-2009, and 2014 Kenya Demographic and Health Surveys and the 2007 and 2012 Kenya AIDS Indicator Surveys. The study included children of female respondents to the 2003, 2008-2009, and 2014 Kenya Demographic and Health Surveys who were born 1 to 60 months (for neonatal mortality) or 12 to 60 months (for infant mortality) before the survey, as well as female respondents who had recently given birth and reported on HIV testing during antenatal care (ANC) during the 2007-2014 surveys. Results were adjusted for year, province, and survey respondent characteristics. Statistical analysis was performed from July 8, 2016, to December 10, 2018. MAIN OUTCOMES AND MEASURES Neonatal mortality was defined as death within the first month of life and infant mortality was defined as death within the first year of life. HIV testing during ANC was defined as receiving counseling on PMTCT, undergoing an HIV test, and receiving test results during ANC. RESULTS The analysis included 33 181 neonates (16 870 boys), 26 876 infants (13 679 boys), and 20 775 mothers (mean [SD] age, 28.0 [6.7] years). PEPFAR funding was not associated with neonatal mortality. A $0.33 increase in annual PCF, corresponding to the difference between the 75th and 25th (interquartile range) percentiles of funding, was significantly associated with a 16% (95% CI, 4%-27%) reduction in infant mortality after a 1-year lag. A 14% to 16% reduction persisted after 2- and 3-year lags, and comparable reductions were observed for unlagged and 1-year lagged cumulative PCF. An increase of 1 interquartile range in cumulative PCF was associated with a 7% (95% CI, 3%-11%) increase in HIV testing during ANC, which intensified with subsequent lags. Between 2004 and 2014, sustained funding levels of $0.33 annual PCF could have averted 118 039 to 273 924 infant deaths. CONCLUSIONS AND RELEVANCE Evidence from publicly available data suggests that PEPFAR's PMTCT funding was associated with a reduction in infant mortality and an increase in HIV testing during ANC in Kenya. The full outcome of funding may not be realized until several years after allocation.
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Affiliation(s)
- Dale A. Barnhart
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Isaac Tsikhutsu
- Henry M. Jackson Foundation Medical Research International, Kericho, Kenya
| | - Duncan Kirui
- Henry M. Jackson Foundation Medical Research International, Kericho, Kenya
| | - Fredrick Sawe
- Henry M. Jackson Foundation Medical Research International, Kericho, Kenya
| | - Jane Muli
- Henry M. Jackson Foundation Medical Research International, Kericho, Kenya
| | - William Sugut
- Henry M. Jackson Foundation Medical Research International, Kericho, Kenya
| | - Nareen Abboud
- Office of the Global AIDS Coordinator and Health Diplomacy Department of State, Washington, DC
| | - Deborah Birx
- Office of the Global AIDS Coordinator and Health Diplomacy Department of State, Washington, DC
| | - Tiffany Hamm
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland
| | - Peter Coakley
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland
| | - Patrick W. Hickey
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland
- Department of Pediatrics, Uniformed Services University, Bethesda, Maryland
| | - Vanessa Wolfman
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland
| | - Elizabeth Lee
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Donna Spiegelman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Center for Methods in Implementation and Prevention Science, Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Global Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Ikeda DJ, Basenero A, Murungu J, Jasmin M, Inimah M, Agins BD. Implementing quality improvement in tuberculosis programming: Lessons learned from the global HIV response. J Clin Tuberc Other Mycobact Dis 2019; 17:100116. [PMID: 31788558 PMCID: PMC6879975 DOI: 10.1016/j.jctube.2019.100116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The quality of care and treatment for tuberculosis (TB) is a major barrier in global efforts to end TB as a global health emergency. Despite a growing recognition of the need to measure, assure, and improve quality of TB services, implementation of quality improvement (QI) activities remains limited. Applying principles of systems thinking, continuous measurement, and root cause analysis, QI represents a proven approach for identifying and addressing performance gaps in healthcare delivery, with demonstrated success in low- and middle-income settings in the areas of HIV/AIDS, maternal, newborn, and child health, and infection control, among others. Drawing from lessons learned in the development of QI programming as part of the global response to HIV, we review key enablers to implementation that may assist NTPs in turning aspirations of high-quality service delivery into action. Under the umbrella of a formal quality management (QM) program, NTPs' attention to planning and coordination, commitment to tracking key processes of care, investment in QI capacity building, and integration of TB QI activities within efforts to advance universal health coverage provide a framework to sustainably implement QI activities.
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Affiliation(s)
- Daniel J Ikeda
- HEALTHQUAL, Division of Global Epidemiology, Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA
| | | | - Joseph Murungu
- HEALTHQUAL, Institute for Global Health Sciences, University of California, San Francisco, Harare, Zimbabwe
| | - Margareth Jasmin
- HEALTHQUAL, Division of Global Epidemiology, Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA
| | | | - Bruce D Agins
- HEALTHQUAL, Division of Global Epidemiology, Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA.,Institute for Implementation Science in Public Health, City University of New York, New York, NY, USA
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15
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Kalyesubula R, Mutyaba I, Rabin T, Andia-Biraro I, Alupo P, Kimuli I, Nabirye S, Kagimu M, Mayanja-Kizza H, Rastegar A, Kamya MR. Trends of admissions and case fatality rates among medical in-patients at a tertiary hospital in Uganda; A four-year retrospective study. PLoS One 2019; 14:e0216060. [PMID: 31086371 PMCID: PMC6516645 DOI: 10.1371/journal.pone.0216060] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 04/14/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Sub-Saharan Africa suffers from a dual burden of infectious and non-communicable diseases. There is limited data on causes and trends of admission and death among patients on the medical wards. Understanding the major drivers of morbidity and mortality would help inform health systems improvements. We determined the causes and trends of admission and mortality among patients admitted to Mulago Hospital, Kampala, Uganda. METHODS AND RESULTS The medical record data base of patients admitted to Mulago Hospital adult medical wards from January 2011 to December 2014 were queried. A detailed history, physical examination and investigations were completed to confirm the diagnosis and identify comorbidities. Any histopathologic diagnoses were made by hematoxylin and eosin tissue staining. We identified the 10 commonest causes of hospitalization, and used Poisson regression to generate annual percentage change to describe the trends in causes of hospitalization. Survival was calculated from the date of admission to the date of death or date of discharge. Cox survival analysis was used to identify factors associate with in-hospital mortality. We used a statistical significance level of p<0.05. A total of 50,624 patients were hospitalized with a median age of 38 (range 13-122) years and 51.7% females. Majority of patients (72%) had an NCD condition as the primary reason for admission. Specific leading causes of morbidity were HIV/AIDS in 30% patients, hypertension in 14%, tuberculosis (TB) in 12%), non-TB pneumonia in11%) and heart failure in 9.3%. There was decline in the proportion of hospitalization due to malaria, TB and pneumonia with an annual percentage change (apc) of -20% to -6% (all p<0.03) with an increase in proportions of admissions due to chronic kidney disease, hypertension, stroke and cancer, with apc 13.4% to 24%(p<0.001). Overall, 8,637(17.1%) died during hospitalization with the highest case fatality rates from non-TB pneumonia (28.8%), TB (27.1%), stroke (26.8%), cancer (26.1%) and HIV/AIDS (25%). HIV-status, age above 50yrs and being male were associated with increased risk of death among patients with infections. CONCLUSION Admissions and case fatality rates for both infectious and non-infectious diseases were high, with declining trends in infectious diseases and a rising trend in NCDs. Health care systems in sub-Saharan region need to prepare to deal with dual burden of disease.
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Affiliation(s)
- Robert Kalyesubula
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- * E-mail:
| | - Innocent Mutyaba
- Department of Medicine, Uganda Cancer Institute, Kampala, Uganda
| | - Tracy Rabin
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Irene Andia-Biraro
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Patricia Alupo
- Department of Medicine, Makerere Lung Institute, Kampala, Uganda
| | - Ivan Kimuli
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Stella Nabirye
- Directorate of Medicine, Mulago National Referral Hospital, Kampala, Uganda
| | - Magid Kagimu
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Harriet Mayanja-Kizza
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Asghar Rastegar
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Moses R. Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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16
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Abstract
Austerity across Africa has been operationalized through World Bank
and IMF structural adjustment programs since the 1980s, later rebranded euphemistically
as poverty reduction strategies in the late 1990s. Austerity’s constraints
on public spending led donors to a “civil society” focus in which NGOs would fill
gaps in basic social services created by public sector contraction. One consequence
was large-scale redirection of growing foreign aid flows away from public services
to international NGOs. Austerity in Africa coincides with the emergence of what
some anthropologists call “audit cultures” among donors. Extraordinary data collection
infrastructures are demanded from recipient organizations in the name of
transparency. However, the Mozambique experience described here reveals that
these intensive audit cultures serve to obscure the destructive effects of NGO proliferation
on public health systems.
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17
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Hauck K, Morton A, Chalkidou K, Chi YL, Culyer A, Levin C, Meacock R, Over M, Thomas R, Vassall A, Verguet S, Smith PC. How can we evaluate the cost-effectiveness of health system strengthening? A typology and illustrations. Soc Sci Med 2019; 220:141-149. [PMID: 30428401 PMCID: PMC6323413 DOI: 10.1016/j.socscimed.2018.10.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/22/2018] [Accepted: 10/31/2018] [Indexed: 11/23/2022]
Abstract
Health interventions often depend on a complex system of human and capital infrastructure that is shared with other interventions, in the form of service delivery platforms, such as healthcare facilities, hospitals, or community services. Most forms of health system strengthening seek to improve the efficiency or effectiveness of such delivery platforms. This paper presents a typology of ways in which health system strengthening can improve the economic efficiency of health services. Three types of health system strengthening are identified and modelled: (1) investment in the efficiency of an existing shared platform that generates positive benefits across a range of existing interventions; (2) relaxing a capacity constraint of an existing shared platform that inhibits the optimization of existing interventions; (3) providing an entirely new shared platform that supports a number of existing or new interventions. Theoretical models are illustrated with examples, and illustrate the importance of considering the portfolio of interventions using a platform, and not just piecemeal individual analysis of those interventions. They show how it is possible to extend principles of conventional cost-effectiveness analysis to identify an optimal balance between investing in health system strengthening and expenditure on specific interventions. The models developed in this paper provide a conceptual framework for evaluating the cost-effectiveness of investments in strengthening healthcare systems and, more broadly, shed light on the role that platforms play in promoting the cost-effectiveness of different interventions.
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Affiliation(s)
- K Hauck
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, Medical School Building, St Mary's Campus, London, W2 1PG, United Kingdom.
| | - A Morton
- Department of Management Science, Strathclyde Business School, University of Strathclyde, 199 Cathedral Street, Glasgow, G4 0QU, United Kingdom.
| | - K Chalkidou
- Center for Global Development, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, Medical School Building, St Mary's Campus, London, W2 1PG, United Kingdom.
| | - Y-Ling Chi
- Global Health and Development Group, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, Medical School Building, St Mary's Campus, London, W2 1PG, United Kingdom.
| | - A Culyer
- Department of Economics and Related Studies, University of York, Heslington, York, YO10 5DD, United Kingdom.
| | - C Levin
- Department of Global Health, University of Washington, NJB Box #359931, 325 Ninths Avenue, Seattle, WA, 98104, USA.
| | - R Meacock
- Centre for Primary Care, The University of Manchester, 4.311 Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, United Kingdom.
| | - M Over
- Center for Global Development, 2055 L Street NW, Fifth Floor, Washington, DC, 20036, USA.
| | - R Thomas
- Department of Health Policy, London School of Economics and Political Science, Cowdray House, Houghton Street, London, WC2A 2AE, United Kingdom.
| | - A Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom.
| | - S Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.
| | - P C Smith
- Imperial College Business School, Imperial College London, South Kensington Campus, London, SW7 2AZ, United Kingdom.
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18
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Menon MP, Coghill A, Mutyaba IO, Phipps WT, Okuku FM, Harlan JM, Orem J, Casper C. Association Between HIV Infection and Cancer Stage at Presentation at the Uganda Cancer Institute. J Glob Oncol 2018; 4:1-9. [PMID: 30241147 PMCID: PMC6180750 DOI: 10.1200/jgo.17.00005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE The HIV epidemic has contributed to the increasing incidence of cancer in sub-Saharan Africa, where most patients with cancer present at an advanced stage. However, improved access to HIV care and treatment centers in sub-Saharan Africa may facilitate earlier diagnosis of cancer among patients who are HIV positive. To test this hypothesis, we characterized the stage of cancer and evaluated the factors associated with advanced stage at presentation among patients in Uganda. METHODS We conducted a retrospective analysis of adult patients with any of four specific cancers who presented for care in Kampala, Uganda, between 2003 and 2010. Demographic, clinical, and laboratory data were abstracted from the medical record, together with the outcome measure of advanced stage of disease (clinical stage III or IV). We identified measures for inclusion in a multivariate logistic regression model. RESULTS We analyzed 731 patients with both AIDS-defining cancers (cervical [43.1%], and non-Hodgkin lymphoma [18.3%]), and non-AIDS-defining cancers (breast [30.0%] and Hodgkin lymphoma [8.6%]). Nearly 80% of all patients presented at an advanced stage and 37% had HIV infection. More than 90% of patients were symptomatic and the median duration of symptoms before presentation was 5 months. In the multivariate model, HIV-positive patients were less likely to present at an advanced stage as were patients with higher hemoglobin and fewer symptoms. CONCLUSION Patients with limited access to primary care may present with advanced cancer because of a delay in diagnosis. However, patients with HIV now have better access to clinical care. Use of this growing infrastructure to increase cancer screening and referral is promising and deserves continued support, because the prognosis of HIV-positive patients with advanced cancer is characterized by poor survival globally.
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Affiliation(s)
- Manoj P. Menon
- Manoj P. Menon, Anna Coghill, Warren
T. Phipps, and Corey Casper, Fred Hutchinson Cancer
Research Center; Manoj P. Menon, Warren T. Phipps,
John M. Harlan, and Corey Casper, University of
Washington, Seattle, WA; and Innocent O. Mutyaba, Fred M.
Okuku, and Jackson Orem, Uganda Cancer Institute,
Kampala, Uganda
- Corresponding author: Manoj P. Menon, MD, MPH, 1100
Fairview Ave N, Seattle, WA 98109; e-mail:
| | - Anna Coghill
- Manoj P. Menon, Anna Coghill, Warren
T. Phipps, and Corey Casper, Fred Hutchinson Cancer
Research Center; Manoj P. Menon, Warren T. Phipps,
John M. Harlan, and Corey Casper, University of
Washington, Seattle, WA; and Innocent O. Mutyaba, Fred M.
Okuku, and Jackson Orem, Uganda Cancer Institute,
Kampala, Uganda
| | - Innocent O. Mutyaba
- Manoj P. Menon, Anna Coghill, Warren
T. Phipps, and Corey Casper, Fred Hutchinson Cancer
Research Center; Manoj P. Menon, Warren T. Phipps,
John M. Harlan, and Corey Casper, University of
Washington, Seattle, WA; and Innocent O. Mutyaba, Fred M.
Okuku, and Jackson Orem, Uganda Cancer Institute,
Kampala, Uganda
| | - Warren T. Phipps
- Manoj P. Menon, Anna Coghill, Warren
T. Phipps, and Corey Casper, Fred Hutchinson Cancer
Research Center; Manoj P. Menon, Warren T. Phipps,
John M. Harlan, and Corey Casper, University of
Washington, Seattle, WA; and Innocent O. Mutyaba, Fred M.
Okuku, and Jackson Orem, Uganda Cancer Institute,
Kampala, Uganda
| | - Fred M. Okuku
- Manoj P. Menon, Anna Coghill, Warren
T. Phipps, and Corey Casper, Fred Hutchinson Cancer
Research Center; Manoj P. Menon, Warren T. Phipps,
John M. Harlan, and Corey Casper, University of
Washington, Seattle, WA; and Innocent O. Mutyaba, Fred M.
Okuku, and Jackson Orem, Uganda Cancer Institute,
Kampala, Uganda
| | - John M. Harlan
- Manoj P. Menon, Anna Coghill, Warren
T. Phipps, and Corey Casper, Fred Hutchinson Cancer
Research Center; Manoj P. Menon, Warren T. Phipps,
John M. Harlan, and Corey Casper, University of
Washington, Seattle, WA; and Innocent O. Mutyaba, Fred M.
Okuku, and Jackson Orem, Uganda Cancer Institute,
Kampala, Uganda
| | - Jackson Orem
- Manoj P. Menon, Anna Coghill, Warren
T. Phipps, and Corey Casper, Fred Hutchinson Cancer
Research Center; Manoj P. Menon, Warren T. Phipps,
John M. Harlan, and Corey Casper, University of
Washington, Seattle, WA; and Innocent O. Mutyaba, Fred M.
Okuku, and Jackson Orem, Uganda Cancer Institute,
Kampala, Uganda
| | - Corey Casper
- Manoj P. Menon, Anna Coghill, Warren
T. Phipps, and Corey Casper, Fred Hutchinson Cancer
Research Center; Manoj P. Menon, Warren T. Phipps,
John M. Harlan, and Corey Casper, University of
Washington, Seattle, WA; and Innocent O. Mutyaba, Fred M.
Okuku, and Jackson Orem, Uganda Cancer Institute,
Kampala, Uganda
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19
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Strengthening the health workforce to support integration of HIV and noncommunicable disease services in sub-Saharan Africa. AIDS 2018; 32 Suppl 1:S47-S54. [PMID: 29952790 DOI: 10.1097/qad.0000000000001895] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The successful expansion of HIV services in sub-Saharan Africa has been a signature achievement of global public health. This article explores health workforce-related lessons from HIV scale-up, their implications for integrating noncommunicable disease (NCD) services into HIV programs, ways to ensure that healthcare workers have the knowledge, skills, resources, and enabling environment they need to provide comprehensive integrated HIV/NCD services, and discussion of a priority research agenda. DESIGN AND METHODS We conducted a scoping review of the published and 'gray' literature and drew upon our cumulative experience designing, implementing and evaluating HIV and NCD programs in low-resource settings. RESULTS AND CONCLUSION Lessons learned from HIV programs include the role of task shifting and the optimal use of multidisciplinary teams. A responsible and adaptable policy environment is also imperative; norms and regulations must keep pace with the growing evidence base for task sharing, and early engagement of regulatory authorities will be needed for successful HIV/NCD integration. Ex-ante consideration of work culture will also be vital, given its impact on the quality of service delivery. Finally, capacity building of a robust interdisciplinary workforce is essential to foster integrated patient-centered care. To succeed, close collaboration between the health and higher education sectors is needed and comprehensive competency-based capacity building plans for various health worker cadres along the education and training continuum are required. We also outline research priorities for HIV/NCD integration in three key domains: governance and policy; education, training, and management; and service delivery.
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20
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Stover B, Lubega F, Namubiru A, Bakengesa E, Luboga SA, Makumbi F, Kiwanuka N, Ndizihiwe A, Mukooyo E, Hurley E, Lim T, Borse NN, Bernhardt J, Wood A, Sheppard L, Barnhart S, Hagopian A. Conducting a Large Public Health Data Collection Project in Uganda: Methods, Tools, and Lessons Learned. JOURNAL OF RESEARCH PRACTICE 2018; 14:M1. [PMID: 30057632 PMCID: PMC6058317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
We report on the implementation experience of carrying out data collection and other activities for a public health evaluation study on whether U.S. President's Emergency Plan for AIDS Relief (PEPFAR) investment improved utilization of health services and health system strengthening in Uganda. The retrospective study period focused on the PEPFAR scale-up, from mid-2005 through mid-2011, a period of expansion of PEPFAR programing and health services. We visited 315 health care facilities in Uganda in 2011 and 2012 to collect routine health management information system data forms, as well as to conduct interviews with health system leaders. An earlier phase of this research project collected data from all 112 health district headquarters, reported elsewhere. This article describes the lessons learned from collecting data from health care facilities, project management, useful technologies, and mistakes. We used several new technologies to facilitate data collection, including portable document scanners, smartphones, and web-based data collection, along with older but reliable technologies such as car batteries for power, folding tables to create space, and letters of introduction from appropriate authorities to create entrée. Research in limited-resource settings requires an approach that values the skills and talents of local people, institutions and government agencies, and a tolerance for the unexpected. The development of personal relationships was key to the success of the project. We observed that capacity building activities were repaid many fold, especially in data management and technology.
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Affiliation(s)
- Bert Stover
- School of Public Health, University of Washington, Seattle, UNITED STATES
| | - Flavia Lubega
- College of Health Science, Makerere University, Kampala, UGANDA
| | - Aidah Namubiru
- College of Health Science, Makerere University, Kampala, UGANDA
| | | | | | | | - Noah Kiwanuka
- College of Health Science, Makerere University, Kampala, UGANDA
| | | | | | - Erin Hurley
- Centers for Disease Control and Prevention, UNITED STATES
| | - Travis Lim
- Centers for Disease Control and Prevention, UNITED STATES
| | - Nagesh N Borse
- Centers for Disease Control and Prevention, UNITED STATES
| | - James Bernhardt
- School of Public Health, University of Washington, Seattle, UNITED STATES
| | - Angela Wood
- School of Public Health, University of Washington, Seattle, UNITED STATES
| | - Lianne Sheppard
- School of Public Health, University of Washington, Seattle, UNITED STATES
| | - Scott Barnhart
- School of Public Health, University of Washington, Seattle, UNITED STATES
| | - Amy Hagopian
- School of Public Health, University of Washington, Seattle, UNITED STATES
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21
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Wollum A, Dansereau E, Fullman N, Achan J, Bannon KA, Burstein R, Conner RO, DeCenso B, Gasasira A, Haakenstad A, Hanlon M, Ikilezi G, Kisia C, Levine AJ, Masters SH, Njuguna P, Okiro EA, Odeny TA, Allen Roberts D, Gakidou E, Duber HC. The effect of facility-based antiretroviral therapy programs on outpatient services in Kenya and Uganda. BMC Health Serv Res 2017; 17:564. [PMID: 28814295 PMCID: PMC5559797 DOI: 10.1186/s12913-017-2512-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 08/04/2017] [Indexed: 12/21/2022] Open
Abstract
Background Considerable debate exists concerning the effects of antiretroviral therapy (ART) service scale-up on non-HIV services and overall health system performance in sub-Saharan Africa. In this study, we examined whether ART services affected trends in non-ART outpatient department (OPD) visits in Kenya and Uganda. Methods Using a nationally representative sample of health facilities in Kenya and Uganda, we estimated the effect of ART programs on OPD visits from 2007 to 2012. We modeled the annual percent change in non-ART OPD visits using hierarchical mixed-effects linear regressions, controlling for a range of facility characteristics. We used four different constructs of ART services to capture the different ways in which the presence, growth, overall, and relative size of ART programs may affect non-ART OPD services. Results Our final sample included 321 health facilities (140 in Kenya and 181 in Uganda). On average, OPD and ART visits increased steadily in Kenya and Uganda between 2007 and 2012. For facilities where ART services were not offered, the average annual increase in OPD visits was 4·2% in Kenya and 13·5% in Uganda. Among facilities that provided ART services, we found average annual OPD volume increases of 7·2% in Kenya and 5·6% in Uganda, with simultaneous annual increases of 13·7% and 12·5% in ART volumes. We did not find a statistically significant relationship between annual changes in OPD services and the presence, growth, overall, or relative size of ART services. However, in a subgroup analysis, we found that Ugandan hospitals that offered ART services had statistically significantly less growth in OPD visits than Ugandan hospitals that did not provide ART services. Conclusions Our findings suggest that ART services in Kenya and Uganda did not have a statistically significant deleterious effects on OPD services between 2007 and 2012, although subgroup analyses indicate variation by facility type. Our findings are encouraging, particularly given recent recommendations for universal access to ART, demonstrating that expanding ART services is not inherently linked to declines in other health services in sub-Saharan Africa.
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Affiliation(s)
- Alexandra Wollum
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave., Suite 600, Seattle, WA, 98121, USA
| | - Emily Dansereau
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave., Suite 600, Seattle, WA, 98121, USA
| | - Nancy Fullman
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave., Suite 600, Seattle, WA, 98121, USA
| | - Jane Achan
- Medical Research Council Unit, Banjul, The, Gambia
| | - Kelsey A Bannon
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave., Suite 600, Seattle, WA, 98121, USA
| | - Roy Burstein
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave., Suite 600, Seattle, WA, 98121, USA
| | - Ruben O Conner
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave., Suite 600, Seattle, WA, 98121, USA
| | - Brendan DeCenso
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave., Suite 600, Seattle, WA, 98121, USA
| | | | | | - Michael Hanlon
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave., Suite 600, Seattle, WA, 98121, USA
| | - Gloria Ikilezi
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave., Suite 600, Seattle, WA, 98121, USA.,Infectious Diseases Research Collaboration, Mulago Hospital Complex, Kampala, Uganda
| | | | - Aubrey J Levine
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave., Suite 600, Seattle, WA, 98121, USA
| | - Samuel H Masters
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Thomas A Odeny
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave., Suite 600, Seattle, WA, 98121, USA
| | - D Allen Roberts
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave., Suite 600, Seattle, WA, 98121, USA
| | - Emmanuela Gakidou
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave., Suite 600, Seattle, WA, 98121, USA
| | - Herbert C Duber
- Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave., Suite 600, Seattle, WA, 98121, USA.
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22
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Doherty T, Besada D, Goga A, Daviaud E, Rohde S, Raphaely N. "If donors woke up tomorrow and said we can't fund you, what would we do?" A health system dynamics analysis of implementation of PMTCT option B+ in Uganda. Global Health 2017; 13:51. [PMID: 28747196 PMCID: PMC5530517 DOI: 10.1186/s12992-017-0272-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 06/26/2017] [Indexed: 01/12/2023] Open
Abstract
Background In October 2012 Uganda extended its prevention of mother to child HIV transmission (PMTCT) policy to Option B+, providing lifelong antiretroviral treatment for HIV positive pregnant and breastfeeding women. The rapid changes and adoptions of new PMTCT policies have not been accompanied by health systems research to explore health system preparedness to implement such programmes. The implementation of Option B+ provides many lessons which can inform the shift to ‘Universal Test and Treat’, a policy which many sub-Saharan African countries are preparing to adopt, despite fragile health systems. Methods This qualitative study of PMTCT Option B+ implementation in Uganda three years following the policy adoption, uses the health system dynamics framework to explore the impacts of this programme on ten elements of the health system. Qualitative data were gathered through rapid appraisal during in-country field work. Key informant interviews and focus group discussions (FGDs) were undertaken with the Ministry of Health, implementing partners, multilateral agencies, district management teams, facility-based health workers and community cadres. A total of 82 individual interviews and 16 focus group discussions were completed. We conducted a simple manifest analysis, using the ten elements of a health system for grouping data into categories and themes. Results Of the ten elements in the health system dynamics framework, context and resources (finances, infrastructure & supplies, and human resources) were the most influential in the implementation of Option B+ in Uganda. Support from international actors and implementing partners attempted to strengthen resources at district level, but had unintended consequences of creating dependence and uncertainty regarding sustainability. Conclusions The health system dynamics framework offers a novel approach to analysis of the effects of implementation of a new policy on critical elements of the health system. Its emphasis on relationships between system elements, population and context is helpful in unpacking impacts of and reactions to pressures on the system, which adds value beyond some previous frameworks.
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Affiliation(s)
- Tanya Doherty
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa. .,School of Public Health, University of the Western Cape, Cape Town, South Africa. .,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Donnela Besada
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Ameena Goga
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.,Department of Paediatrics, University of Pretoria, Pretoria, South Africa
| | - Emmanuelle Daviaud
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Sarah Rohde
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Nika Raphaely
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Gender and Health Research Unit, South African Medical Research Council, Pretoria, South Africa
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23
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Lohman N, Hagopian A, Luboga SA, Stover B, Lim T, Makumbi F, Kiwanuka N, Lubega F, Ndizihiwe A, Mukooyo E, Barnhart S, Pfeiffer J. District Health Officer Perceptions of PEPFAR's Influence on the Health System in Uganda, 2005-2011. Int J Health Policy Manag 2017; 6:83-95. [PMID: 28812783 PMCID: PMC5287933 DOI: 10.15171/ijhpm.2016.98] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 07/18/2016] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Vertically oriented global health initiatives (GHIs) addressing the HIV/AIDS epidemic, including the President's Emergency Plan for AIDS Relief (PEPFAR), have successfully contributed to reducing HIV/AIDS related morbidity and mortality. However, there is still debate about whether these disease-specific programs have improved or harmed health systems overall, especially with respect to non-HIV health needs. METHODS As part of a larger evaluation of PEPFAR's effects on the health system between 2005-2011, we collected qualitative and quantitative data through semi-structured interviews with District Health Officers (DHOs) from all 112 districts in Uganda. We asked DHOs to share their perceptions about the ways in which HIV programs (largely PEPFAR in the Ugandan context) had helped and harmed the health system. We then identified key themes among their responses using qualitative content analysis. RESULTS Ugandan DHOs said PEPFAR had generally helped the health system by improving training, integrating HIV and non-HIV care, and directly providing resources. To a lesser extent, DHOs said PEPFAR caused the health system to focus too narrowly on HIV/AIDS, increased workload for already overburdened staff, and encouraged doctors to leave public sector jobs for higher-paid positions with HIV/AIDS programs. CONCLUSION Health system leaders in Uganda at the district level were appreciative of resources aimed at HIV they could often apply for broader purposes. As HIV infection becomes a chronic disease requiring strong health systems to manage sustained patient care over time, Uganda's weak health systems will require broad infrastructure improvements inconsistent with narrow vertical health programming.
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Affiliation(s)
- Nathaniel Lohman
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Amy Hagopian
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
| | | | - Bert Stover
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Travis Lim
- Division of Global HIV and Tuberculosis, Atlanta, GA, USA
| | | | - Noah Kiwanuka
- Faculty of Health Sciences, Makerere University, Kampala, Uganda
| | - Flavia Lubega
- Faculty of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Eddie Mukooyo
- Resource Center for the Uganda Ministry of Health, Uganda Ministry of Health, Nakasero, Uganda
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - James Pfeiffer
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Health Services, University of Washington, Seattle, WA, USA
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24
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Topp SM, Chipukuma JM. How did rapid scale-up of HIV services impact on workplace and interpersonal trust in Zambian primary health centres: a case-based health systems analysis. BMJ Glob Health 2016; 1:e000179. [PMID: 28588985 PMCID: PMC5321392 DOI: 10.1136/bmjgh-2016-000179] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 11/07/2016] [Accepted: 11/24/2016] [Indexed: 11/09/2022] Open
Abstract
Background In sub-Saharan Africa, large amounts of funding continue to be directed towards HIV-specific care and treatment, often with claims of ‘health system strengthening’ effect. Such claims rarely account for the impact on human relationships and decisions that are core to functional health systems. This research examined how establishment of externally funded HIV services influenced trusting relationships in Zambian health centres. Methods An in-depth, multicase study included four health centres selected for urban, peri-urban and rural characteristics. Case data included healthcare worker (HCW) interviews (60); patient interviews (180); direct observation of facility operations (2 weeks/centre) and key informant interviews (14) which were recorded and transcribed verbatim. Thematic analysis adopted inductive and deductive coding guided by a framework incorporating concepts of workplace trust, patient–provider trust, intrinsic and extrinsic motivation. Results HIV service scale-up impacted trust in positive and negative ways. Investment in HIV-specific infrastructure, supplies and quality assurance mechanisms strengthened workplace trust, HCW motivation and patient–provider trust in HIV departments in the short-term. In the health centres more broadly and over time, however, non-governmental organisation-led investment and support of HIV departments reinforced HCW's perceptions of the government as uninterested or unable to provide a quality work environment. Exacerbating existing perceptions of systemic workplace inequity and nepotism, uneven distribution of personal and professional opportunities related to HIV service establishment contributed to interdepartmental antagonism and reinforced workplace practices designed to protect individual HCW's interests. Conclusions Findings illustrate long-term negative effects of the vertical HIV resourcing and support structures which failed to address and sometimes exacerbated HCW (dis)trust with their own government and supervisors. The short-term and long-term effects of weakened workplace trust on HCWs' motivation and performance signal the importance of understanding how such relationships play a role in generating virtuous or perverse cycles of actor interactions, with implications for service outcomes.
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Affiliation(s)
- Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia.,Nossal Institute for Global Health, University of Melbourne, Melbourne, Victoria, Australia
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25
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Zakumumpa H, Bennett S, Ssengooba F. Accounting for variations in ART program sustainability outcomes in health facilities in Uganda: a comparative case study analysis. BMC Health Serv Res 2016; 16:584. [PMID: 27756359 PMCID: PMC5070310 DOI: 10.1186/s12913-016-1833-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 10/08/2016] [Indexed: 11/13/2022] Open
Abstract
Background Uganda implemented a national ART scale-up program at public and private health facilities between 2004 and 2009. Little is known about how and why some health facilities have sustained ART programs and why others have not sustained these interventions. The objective of the study was to identify facilitators and barriers to the long-term sustainability of ART programs at six health facilities in Uganda which received donor support to commence ART between 2004 and 2009. Methods A case-study approach was adopted. Six health facilities were purposively selected for in-depth study from a national sample of 195 health facilities across Uganda which participated in an earlier study phase. The six health facilities were placed in three categories of sustainability; High Sustainers (2), Low Sustainers (2) and Non- Sustainers (2). Semi-structured interviews with ART Clinic managers (N = 18) were conducted. Questionnaire data were analyzed (N = 12). Document review augmented respondent data. Based on the data generated, across-case comparative analyses were performed. Data were collected between February and June 2015. Results Several distinguishing features were found between High Sustainers, and Low and Non-Sustainers’ ART program characteristics. High Sustainers had larger ART programs with higher staffing and patient volumes, a broader ‘menu’ of ART services and more stable program leadership compared to the other cases. High Sustainers associated sustained ART programs with multiple funding streams, robust ART program evaluation systems and having internal and external program champions. Low and Non Sustainers reported similar barriers of shortage and attrition of ART-proficient staff, low capacity for ART program reporting, irregular and insufficient supply of ARV drugs and a lack of alignment between ART scale-up and their for-profit orientation in three of the cases. Conclusions We found that ART program sustainability was embedded in a complex system involving dynamic interactions between internal (program champion, staffing strength, M &E systems, goal clarity) and external drivers (donors, ARVs supply chain, patient demand). ART program sustainability contexts were distinguished by the size of health facility and ownership-type. The study’s implications for health systems strengthening in resource-limited countries are discussed.
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Affiliation(s)
- Henry Zakumumpa
- Makerere University, School of Public Health, Kampala, Uganda.
| | - Sara Bennett
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
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