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Mweemba C, Mutale W, Masiye F, Hangoma P. Why is there a gap in self-rated health among people with hypertension in Zambia? A decomposition of determinants and rural‒urban differences. BMC Public Health 2024; 24:1025. [PMID: 38609942 PMCID: PMC11015612 DOI: 10.1186/s12889-024-18429-6] [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: 11/03/2023] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Hypertension affects over one billion people globally and is one of the leading causes of premature death. Low- and middle-income countries, especially the sub-Saharan Africa region, bear a disproportionately higher share of hypertension globally. Recent evidence shows a steady shift in the burden of hypertension from more affluent and urban populations towards poorer and rural communities. Our study examined inequalities in self-rated health (SRH) among people with hypertension and whether there is a rural‒urban gap in the health of these patients. We then quantified factors driving the health gap. We also examined how much HIV accounts for differences in self-rated health among hypertension patients due to the relationship between HIV, hypertension and health in sub-Saharan Africa. METHODS We utilized the Zambia Household Health Expenditure and Utilization Survey for data on SRH and other demographic and socioeconomic controls. District HIV prevalence information was from the Zambia Population-Based HIV Impact Assessment (ZAMPHIA) survey. We applied the Linear Probability Model to assess the association between self-rated health and independent variables as a preliminary step. We then used the Blinder-Oaxaca decomposition to identify self-rated health inequality between urban and rural patients and determine determinants of the health gap between the two groups. RESULTS Advanced age, lower education and low district HIV prevalence were significantly associated with poor health rating among hypertension patients. The decomposition analysis indicated that 45.5% of urban patients and 36.9% of rural patients reported good self-rated health, representing a statistically significant health gap of 8.6%. Most of the identified health gap can be attributed to endowment effects, with education (73.6%), district HIV prevalence (30.8%) and household expenditure (4.8%) being the most important determinants that explain the health gap. CONCLUSIONS Urban hypertension patients have better SRH than rural patients in Zambia. Education, district HIV prevalence and household expenditure were the most important determinants of the health gap between rural and urban hypertension patients. Policies aimed at promoting educational interventions, improving access to financial resources and strengthening hypertension health services, especially in rural areas, can significantly improve the health of rural patients, and potentially reduce health inequalities between the two regions.
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Affiliation(s)
- Chris Mweemba
- Department of Health Policy and Management, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, P.O. Box 50110, Zambia.
| | - Wilbroad Mutale
- Department of Health Policy and Management, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, P.O. Box 50110, Zambia
| | - Felix Masiye
- Department of Economics, School of Humanities and Social Science, Great East Road Campus, Lusaka, P.O Box 32379, Zambia
| | - Peter Hangoma
- Department of Health Policy and Management, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, P.O. Box 50110, Zambia
- Chr. Michelson Institute (CMI), Bergen, Norway
- Bergen Center for Ethics and Priority Setting in Health, University of Bergen, Bergen, Norway
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Lee NM, Singini D, Janes CR, Grépin KA, Liu JA. Identifying barriers to the production and use of routine health information in Western Province, Zambia. Health Policy Plan 2023; 38:996-1005. [PMID: 37655995 PMCID: PMC10566315 DOI: 10.1093/heapol/czad077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 07/21/2023] [Accepted: 08/30/2023] [Indexed: 09/02/2023] Open
Abstract
Recent decades of improvements to routine health information systems in low- and middle-income countries (LMICs) have increased the volume of health data collected. However, countries continue to face several challenges with quality production and use of information for decision-making at sub-national levels, limiting the value of health information for policy, planning and research. Improving the quality of data production and information use is thus a priority in many LMICs to improve decision-making and health outcomes. This qualitative study identified the challenges of producing and using routine health information in Western Province, Zambia. We analysed the interview responses from 37 health and social sector professionals at the national, provincial, district and facility levels to understand the barriers to using data from the Zambian health management information system (HMIS). Respondents raised several challenges that we categorized into four themes: governance and health system organization, geographic barriers, technical and procedural barriers, and challenges with human resource capacity and staff training. Staff at the facility and district levels were arguably the most impacted by these barriers as they are responsible for much of the labour to collect and report routine data. However, facility and district staff had the least authority and ability to mitigate the barriers to data production and information use. Expectations for information use should therefore be clearly outlined for each level of the health system. Further research is needed to understand to what extent the available HMIS data address the needs and purposes of the staff at facilities and districts.
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Affiliation(s)
- Na-Mee Lee
- School of Public Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
| | - Douglas Singini
- School of Public Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
- Western Province Health Office, Plot No. 4503, Independence Avenue, Mongu, Western Province, Zambia
| | - Craig R Janes
- School of Public Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
| | - Karen A Grépin
- School of Public Health, University of Hong Kong, 7 Sassoon Road, Pokfulam, Hong Kong Special Administrative Region, China
| | - Jennifer A Liu
- School of Public Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
- Department of Anthropology, University of Waterloo, 200 University Avenue West, Waterloo, Ontario N2L 3G1, Canada
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Mweemba C, Mutale W, Masiye F, Hangoma P. Why is there a gap in self-rated health among people with hypertension? A decomposition of determinants and rural-urban differences. RESEARCH SQUARE 2023:rs.3.rs-3111338. [PMID: 37461663 PMCID: PMC10350196 DOI: 10.21203/rs.3.rs-3111338/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Background Hypertension affects over one billion people globally and is one of the leading causes of premature death. The low- and middle-income countries, especially the sub-Saharan Africa region, bear a disproportionately higher share of hypertension globally. Recent evidence shows a steady shift in the burden of hypertension from the more affluent and urban population towards the poorer and rural communities. Our study examined inequalities in self-rated health among people with hypertension and whether there is a rural-urban gap in the health of these patients. We then quantified factors driving the health gap. We also examined how much HIV accounts for differences in self-rated health among hypertension patients due to the relationship between HIV, hypertension and health in sub-Saharan Africa. Methods We utilized the Zambia Household Health Expenditure and Utilization Survey for the data on SRH and other demographic and socioeconomic controls. District HIV prevalence information was from a previous study. The linear probability model provided a preliminary assessment of the association between self-rated health and independent variables. We then used the Blinder-Oaxaca decomposition to identify self-rated health inequality between urban and rural patients and determine determinants of the health gap between the two groups. Results Advanced age, lower education and low district HIV prevalence were significantly associated with poor health rating among hypertension patients. The decomposition analysis indicated that 45.5% of urban patients and 36.9% of rural patients reported good self-rated health, representing a statistically significant health gap of 8.6%. Most of the identified health gap can be attributed to endowment effects, with education (62%), district HIV prevalence (26%) and household expenditure (12%) being the most important determinants that explain the health gap. Conclusions Urban hypertension patients have better SRH than rural patients in Zambia. Educational interventions, financial protection schemes and strengthening hypertension health services in rural areas can significantly reduce the health gap between the two regions.
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Affiliation(s)
- Chris Mweemba
- Department of Health Policy and Management, School of Public Health, P.O. Box 50110, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Wilbroad Mutale
- Department of Health Policy and Management, School of Public Health, P.O. Box 50110, Ridgeway Campus, University of Zambia, Lusaka, Zambia
| | - Felix Masiye
- Department of Economics, School of Humanities and Social Science, P.O Box 32379, Great East Road Campus, University of Zambia, Lusaka, Zambia
| | - Peter Hangoma
- Department of Health Policy and Management, School of Public Health, P.O. Box 50110, Ridgeway Campus, University of Zambia, Lusaka, Zambia
- Chr. Michelson Institute (CMI), Bergen, Norway
- Bergen Center for Ethics and Priority Setting in Health, University of Bergen, Bergen, Norway
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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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Underutilisation of routinely collected data in the HIV programme in Zambia: a review of quantitatively analysed peer-reviewed articles. Health Res Policy Syst 2017; 15:51. [PMID: 28610616 PMCID: PMC5470192 DOI: 10.1186/s12961-017-0221-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 05/30/2017] [Indexed: 01/23/2023] Open
Abstract
Background The extent to which routinely collected HIV data from Zambia has been used in peer-reviewed published articles remains unexplored. This paper is an analysis of peer-reviewed articles that utilised routinely collected HIV data from Zambia within six programme areas from 2004 to 2014. Methods Articles on HIV, published in English, listed in the Directory of open access journals, African Journals Online, Google scholar, and PubMed were reviewed. Only articles from peer-reviewed journals, that utilised routinely collected data and included quantitative data analysis methods were included. Multi-country studies involving Zambia and another country, where the specific results for Zambia were not reported, as well as clinical trials and intervention studies that did not take place under routine care conditions were excluded, although community trials which referred patients to the routine clinics were included. Independent extraction was conducted using a predesigned data collection form. Pooled analysis was not possible due to diversity in topics reviewed. Results A total of 69 articles were extracted for review. Of these, 7 were excluded. From the 62 articles reviewed, 39 focused on HIV treatment and retention in care, 15 addressed prevention of mother-to-child transmission, 4 assessed social behavioural change, and 4 reported on voluntary counselling and testing. In our search, no articles were found on condom programming or voluntary male medical circumcision. The most common outcome measures reported were CD4+ count, clinical failure or mortality. The population analysed was children in 13 articles, women in 16 articles, and both adult men and women in 33 articles. Conclusion During the 10 year period of review, only 62 articles were published analysing routinely collected HIV data in Zambia. Serious consideration needs to be made to maximise the utility of routinely collected data, and to benefit from the funds and efforts to collect these data. This could be achieved with government support of operational research and publication of findings based on routinely collected Zambian HIV data.
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Modi S, Callahan T, Rodrigues J, Kajoka MD, Dale HM, Langa JO, Urso M, Nchephe MI, Bongdene H, Romano S, Broyles LN. Overcoming Health System Challenges for Women and Children Living With HIV Through the Global Plan. J Acquir Immune Defic Syndr 2017; 75 Suppl 1:S76-S85. [PMID: 28399000 PMCID: PMC5615405 DOI: 10.1097/qai.0000000000001336] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To meet the ambitious targets set by the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan), the initial 22 priority countries quickly developed innovative approaches for overcoming long-standing health systems challenges and providing HIV testing and treatment to pregnant and breastfeeding women and their infants. The Global Plan spurred programs for prevention of mother-to-child HIV transmission to integrate HIV-related care and treatment into broader maternal, newborn, and child health services; expand the effectiveness of the health workforce through task sharing; extend health services into communities; strengthen supply chain and commodity management systems; reduce diagnostic and laboratory hurdles; and strengthen strategic supervision and mentorship. The article reviews the ongoing challenges for prevention of mother-to-child HIV transmission programs as they continue to strive for elimination of vertical transmission of HIV infection in the post-Global Plan era. Although progress has been rapid, health systems still face important challenges, particularly follow-up and diagnosis of HIV-exposed infants, continuity of care, and the promotion of services that are respectful and client centered.
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Affiliation(s)
- Surbhi Modi
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA
| | - Tegan Callahan
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Mwikemo D. Kajoka
- Department of Preventive Services, Reproductive and Child Health Section, PMTCT Programme Ministry of Health, Community Development, Gender, Elderly, and Children, Dar es Salaam, United Republic of Tanzania
| | - Helen M. Dale
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA
| | - Judite O. Langa
- Division of Global HIV and Tuberculosis Centers for Disease Control and Prevention, Maputo, Mozambique
| | - Marilena Urso
- Division of Global HIV and Tuberculosis Centers for Disease Control and Prevention, Maputo, Mozambique
| | | | | | - Sostena Romano
- HIV/AIDS Section United Nations Children’s Fund, New York, NY
| | - Laura N. Broyles
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA
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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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Abstract
This article examines the effect of introducing a new HIV/AIDS service-prevention of mother-to-child transmission of HIV (PMTCT)-on overall quality of prenatal and postnatal care. My results suggest that local PMTCT introduction in Zambia may have actually increased all-cause child mortality in the short term. There is some evidence that vaccinations may have declined in the short term in association with local PMTCT introduction, suggesting that the new service may have partly crowded out existing pediatric health services.
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Affiliation(s)
- Nicholas Wilson
- Department of Economics, Reed College, Portland, OR, 97202, USA.
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Harris FM, Maxwell M, O’Connor R, Coyne JC, Arensman E, Coffey C, Koburger N, Gusmão R, Costa S, Székely A, Cserhati Z, McDaid D, van Audenhove C, Hegerl U. Exploring synergistic interactions and catalysts in complex interventions: longitudinal, mixed methods case studies of an optimised multi-level suicide prevention intervention in four european countries (Ospi-Europe). BMC Public Health 2016; 16:268. [PMID: 26979461 PMCID: PMC4791791 DOI: 10.1186/s12889-016-2942-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 03/08/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The Medical Research Council (MRC) Framework for complex interventions highlights the need to explore interactions between components of complex interventions, but this has not yet been fully explored within complex, non-pharmacological interventions. This paper draws on the process evaluation data of a suicide prevention programme implemented in four European countries to illustrate the synergistic interactions between intervention levels in a complex programme, and to present our method for exploring these. METHODS A realist evaluation approach informed the process evaluation, which drew on mixed methods, longitudinal case studies. Data collection consisted of 47 semi-structured interviews, 12 focus groups, one workshop, fieldnoted observations of six programme meetings and 20 questionnaires (delivered at six month intervals to each of the four intervention sites). Analysis drew on the framework approach, facilitated by the use of QSR NVivo (v10). Our qualitative approach to exploring synergistic interactions (QuaSIC) also developed a matrix of hypothesised synergies that were explored within one workshop and two waves of data collection. RESULTS All four implementation countries provided examples of synergistic interactions that added value beyond the sum of individual intervention levels or components in isolation. For instance, the launch ceremony of the public health campaign (a level 3 intervention) in Ireland had an impact on the community-based professional training, increasing uptake and visibility of training for journalists in particular. In turn, this led to increased media reporting of OSPI activities (monitored as part of the public health campaign) and also led to wider dissemination of editorial guidelines for responsible reporting of suicidal acts. Analysis of the total process evaluation dataset also revealed the new phenomenon of the OSPI programme acting as a catalyst for externally generated (and funded) activity that shared the goals of suicide prevention. CONCLUSIONS The QuaSIC approach enabled us to develop and refine our definition of synergistic interactions and add the innovative concept of catalytic effects. This represents a novel approach to the evaluation of complex interventions. By exploring synergies and catalytic interactions related to a complex intervention or programme, we reveal the added value to planned activities and how they might be maximised.
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Affiliation(s)
- Fiona M. Harris
- />Nursing, Midwifery & Allied Health Professions Research Unit, University of Stirling, Unit 13, University of Stirling Innovation Park, Stirling, FK9 4NF UK
| | - Margaret Maxwell
- />Nursing, Midwifery & Allied Health Professions Research Unit, University of Stirling, Unit 13, University of Stirling Innovation Park, Stirling, FK9 4NF UK
| | - Rory O’Connor
- />Institute of Health & Well-being, University of Glasgow, Glasgow, UK
| | - James C. Coyne
- />Faculty of Medical Sciences, University of Groningen, Groningen, The Netherlands
| | - Ella Arensman
- />National Suicide Research Foundation, University College Cork, Cork, Ireland
| | - Claire Coffey
- />National Suicide Research Foundation, University College Cork, Cork, Ireland
| | - Nicole Koburger
- />Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany
| | - Ricardo Gusmão
- />CEDOC, Faculdade e Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Susana Costa
- />CEDOC, Faculdade e Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - András Székely
- />Institute of Behavioural Sciences, Semmelweis University Budapest, Budapest, Hungary
| | - Zoltan Cserhati
- />Institute of Behavioural Sciences, Semmelweis University Budapest, Budapest, Hungary
| | - David McDaid
- />Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | | | - Ulrich Hegerl
- />Department of Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany
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Dansereau E, Masiye F, Gakidou E, Masters SH, Burstein R, Kumar S. Patient satisfaction and perceived quality of care: evidence from a cross-sectional national exit survey of HIV and non-HIV service users in Zambia. BMJ Open 2015; 5:e009700. [PMID: 26719321 PMCID: PMC4710828 DOI: 10.1136/bmjopen-2015-009700] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine the associations between perceived quality of care and patient satisfaction among HIV and non-HIV patients in Zambia. SETTING Patient exit survey conducted at 104 primary, secondary and tertiary health clinics across 16 Zambian districts. PARTICIPANTS 2789 exiting patients. PRIMARY INDEPENDENT VARIABLES Five dimensions of perceived quality of care (health personnel practice and conduct, adequacy of resources and services, healthcare delivery, accessibility of care, and cost of care). SECONDARY INDEPENDENT VARIABLES Respondent, visit-related, and facility characteristics. PRIMARY OUTCOME MEASURE Patient satisfaction measured on a 1-10 scale. METHODS Indices of perceived quality of care were modelled using principal component analysis. Statistical associations between perceived quality of care and patient satisfaction were examined using random-effect ordered logistic regression models, adjusting for demographic, socioeconomic, visit and facility characteristics. RESULTS Average satisfaction was 6.9 on a 10-point scale for non-HIV services and 7.3 for HIV services. Favourable perceptions of health personnel conduct were associated with higher odds of overall satisfaction for non-HIV (OR=3.53, 95% CI 2.34 to 5.33) and HIV (OR=11.00, 95% CI 3.97 to 30.51) visits. Better perceptions of resources and services were also associated with higher odds of satisfaction for both non-HIV (OR=1.66, 95% CI 1.08 to 2.55) and HIV (OR=4.68, 95% CI 1.81 to 12.10) visits. Two additional dimensions of perceived quality of care--healthcare delivery and accessibility of care--were positively associated with higher satisfaction for non-HIV patients. The odds of overall satisfaction were lower in rural facilities for non-HIV patients (OR 0.69; 95% CI 0.48 to 0.99) and HIV patients (OR=0.26, 95% CI 0.16 to 0.41). For non-HIV patients, the odds of satisfaction were greater in hospitals compared with health centres/posts (OR 1.78; 95% CI 1.27 to 2.48) and lower at publicly-managed facilities (OR=0.41, 95% CI=0.27 to 0.64). CONCLUSIONS Perceived quality of care is an important driver of patient satisfaction with health service delivery in Zambia.
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Affiliation(s)
- Emily Dansereau
- Department of Public Health, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | - Felix Masiye
- Department of Economics, University of Zambia, Lusaka, Zambia
| | - Emmanuela Gakidou
- Department of Public Health, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | - Samuel H Masters
- Department of Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Roy Burstein
- Department of Public Health, Institute for Health Metrics and Evaluation, Seattle, Washington, USA
| | - Santosh Kumar
- Department of Economics & International Business, Sam Houston State University, Huntsville, Texas, USA
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Kruk ME, Rabkin M, Grépin KA, Austin-Evelyn K, Greeson D, Masvawure TB, Sacks ER, Vail D, Galea S. 'Big push' to reduce maternal mortality in Uganda and Zambia enhanced health systems but lacked a sustainability plan. Health Aff (Millwood) 2015; 33:1058-66. [PMID: 24889956 DOI: 10.1377/hlthaff.2013.0637] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the past decade, "big push" global health initiatives financed by international donors have aimed to rapidly reach ambitious health targets in low-income countries. The health system impacts of these efforts are infrequently assessed. Saving Mothers, Giving Life is a global public-private partnership that aims to reduce maternal mortality dramatically in one year in eight districts in Uganda and Zambia. We evaluated the first six to twelve months of the program's implementation, its ownership by national ministries of health, and its effects on health systems. The project's impact on maternal mortality is not reported here. We found that the Saving Mothers, Giving Life initiative delivered a large "dose" of intervention quickly by capitalizing on existing US international health assistance platforms, such as the President's Emergency Plan for AIDS Relief. Early benefits to the broader health system included greater policy attention to maternal and child health, new health care infrastructure, and new models for collaborating with the private sector and communities. However, the rapid pace, external design, and lack of a long-term financing plan hindered integration into the health system and local ownership. Sustaining and scaling up early gains of similar big push initiatives requires longer-term commitments and a clear plan for transition to national control.
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Affiliation(s)
- Margaret E Kruk
- Margaret E. Kruk is an assistant professor of health policy and management and director of the Better Health Systems Initiative at the Columbia University Mailman School of Public Health, in New York City
| | - Miriam Rabkin
- Miriam Rabkin is an associate professor of epidemiology at the Columbia University Medical Center and director for health systems strategies at ICAP at Columbia University
| | - Karen Ann Grépin
- Karen Ann Grépin is an assistant professor of global health policy at the Robert F. Wagner Graduate School of Public Service, New York University, in New York City
| | - Katherine Austin-Evelyn
- Katherine Austin-Evelyn is a researcher in the Department of Epidemiology, Columbia University Mailman School of Public Health
| | - Dana Greeson
- Dana Greeson is a researcher in the Department of Epidemiology, Columbia University Mailman School of Public Health
| | - Tsitsi Beatrice Masvawure
- Tsitsi Beatrice Masvawure is a researcher in the Department of Epidemiology, Columbia University Mailman School of Public Health
| | - Emma Rose Sacks
- Emma Rose Sacks is a researcher in the Department of Epidemiology, Columbia University Mailman School of Public Health
| | - Daniel Vail
- Daniel Vail is a researcher in the Department of Epidemiology, Columbia University Mailman School of Public Health
| | - Sandro Galea
- Sandro Galea is chair of and the Gelman Professor of Epidemiology in the Department of Epidemiology, Columbia University Mailman School of Public Health
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Colson KE, Dwyer-Lindgren L, Achoki T, Fullman N, Schneider M, Mulenga P, Hangoma P, Ng M, Masiye F, Gakidou E. Benchmarking health system performance across districts in Zambia: a systematic analysis of levels and trends in key maternal and child health interventions from 1990 to 2010. BMC Med 2015; 13:69. [PMID: 25889124 PMCID: PMC4382853 DOI: 10.1186/s12916-015-0308-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 03/02/2015] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Achieving universal health coverage and reducing health inequalities are primary goals for an increasing number of health systems worldwide. Timely and accurate measurements of levels and trends in key health indicators at local levels are crucial to assess progress and identify drivers of success and areas that may be lagging behind. METHODS We generated estimates of 17 key maternal and child health indicators for Zambia's 72 districts from 1990 to 2010 using surveys, censuses, and administrative data. We used a three-step statistical model involving spatial-temporal smoothing and Gaussian process regression. We generated estimates at the national level for each indicator by calculating the population-weighted mean of the district values and calculated composite coverage as the average of 10 priority interventions. RESULTS National estimates masked substantial variation across districts in the levels and trends of all indicators. Overall, composite coverage increased from 46% in 1990 to 73% in 2010, and most of this gain was attributable to the scale-up of malaria control interventions, pentavalent immunization, and exclusive breastfeeding. The scale-up of these interventions was relatively equitable across districts. In contrast, progress in routine services, including polio immunization, antenatal care, and skilled birth attendance, stagnated or declined and exhibited large disparities across districts. The absolute difference in composite coverage between the highest-performing and lowest-performing districts declined from 37 to 26 percentage points between 1990 and 2010, although considerable variation in composite coverage across districts persisted. CONCLUSIONS Zambia has made marked progress in delivering maternal and child health interventions between 1990 and 2010; nevertheless, substantial variations across districts and interventions remained. Subnational benchmarking is important to identify these disparities, allowing policymakers to prioritize areas of greatest need. Analyses such as this one should be conducted regularly and feed directly into policy decisions in order to increase accountability at the local, regional, and national levels.
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Affiliation(s)
| | - Laura Dwyer-Lindgren
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
| | - Tom Achoki
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
- Ministry of Health of Botswana, Gaborone, Botswana.
| | - Nancy Fullman
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
| | | | | | - Peter Hangoma
- Department of Economics, University of Bergen, Bergen, Norway.
- Department of Economics, University of Zambia, Lusaka, Zambia.
| | - Marie Ng
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
| | - Felix Masiye
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
- Department of Economics, University of Zambia, Lusaka, Zambia.
| | - Emmanuela Gakidou
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
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Topp SM, Black J, Morrow M, Chipukuma JM, Van Damme W. The impact of human immunodeficiency virus (HIV) service scale-up on mechanisms of accountability in Zambian primary health centres: a case-based health systems analysis. BMC Health Serv Res 2015; 15:67. [PMID: 25889803 PMCID: PMC4347932 DOI: 10.1186/s12913-015-0703-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 01/13/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Questions about the impact of large donor-funded HIV interventions on low- and middle-income countries' health systems have been the subject of a number of expert commentaries, but comparatively few empirical research studies. Aimed at addressing a particular evidence gap vis-à-vis the influence of HIV service scale-up on micro-level health systems, this article examines the impact of HIV scale-up on mechanisms of accountability in Zambian primary health facilities. METHODS Guided by the Mechanisms of Effect framework and Brinkerhoff's work on accountability, we conducted an in-depth multi-case study to examine how HIV services influenced mechanisms of administrative and social accountability in four Zambian primary health centres. Sites were selected for established (over 3 yrs) antiretroviral therapy (ART) services and urban, peri-urban and rural characteristics. Case data included provider interviews (60); patient interviews (180); direct observation of facility operations (2 wks/centre) and key informant interviews (14). RESULTS Resource-intensive investment in HIV services contributed to some early gains in administrative answerability within the four ART departments, helping to establish the material capabilities necessary to deliver and monitor service delivery. Simultaneous investment in external supervision and professional development helped to promote transparency around individual and team performance and also strengthened positive work norms in the ART departments. In the wider health centres, however, mechanisms of administrative accountability remained weak, hindered by poor data collection and under capacitated leadership. Substantive gains in social accountability were also elusive as HIV scale-up did little to address deeply rooted information and power asymmetries in the wider facilities. CONCLUSIONS Short terms gains in primary-level service accountability may arise from investment in health system hardware. However, sustained improvements in service quality and responsiveness arising from genuine improvements in social and administrative accountability require greater understanding of, and investment in changing, the power relations, work norms, leadership and disciplinary mechanisms that shape these micro-level health systems.
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Affiliation(s)
- Stephanie M Topp
- Schools of Public Health and Medicine, University of Alabama, Birmingham, USA.
- Centre for Infectious Disease Research in Zambia, PO Box 30338, Lusaka, Zambia.
- Nossal Institute for Global Health, University of Melbourne, Level 4, 161 Barry Street, Alan Gilbert Building, Carlton, 3010, VIC, Australia.
| | - Jim Black
- Nossal Institute for Global Health, University of Melbourne, Level 4, 161 Barry Street, Alan Gilbert Building, Carlton, 3010, VIC, Australia.
| | - Martha Morrow
- Nossal Institute for Global Health, University of Melbourne, Level 4, 161 Barry Street, Alan Gilbert Building, Carlton, 3010, VIC, Australia.
| | - Julien M Chipukuma
- University of Lusaka, Plot No 37413, Mass Media, Lusaka, 101010, Zambia.
| | - Wim Van Damme
- Public Health and Health Policy Unit, ITM-Antwerp, Sint-Rochusstraat 2, 2000, Antwerpen, Belgium.
- School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville, 7535, Republic of South Africa.
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Kruk ME, Jakubowski A, Rabkin M, Kimanga DO, Kundu F, Lim T, Lumumba V, Oluoch T, Robinson KA, El-Sadr W. Association between HIV programs and quality of maternal health inputs and processes in Kenya. Am J Public Health 2015; 105 Suppl 2:S207-10. [PMID: 25689188 DOI: 10.2105/ajph.2014.302511] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
We assessed whether quality of maternal and newborn health services is influenced by presence of HIV programs at Kenyan health facilities using data from a national facility survey. Facilities that provided services to prevent mother-to-child HIV transmission had better prenatal and postnatal care inputs, such as infrastructure and supplies, and those providing antiretroviral therapy had better quality of prenatal and postnatal care processes. HIV-related programs may have benefits for quality of care for related services in the health system.
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Affiliation(s)
- Margaret E Kruk
- At the time of the study, Margaret E. Kruk and Aleksandra Jakubowski were with the Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY. Miriam Rabkin and Wafaa El-Sadr are with the Departments of Epidemiology and Medicine, Columbia University, New York. At the time of this research, Davies O. Kimanga was with the National AIDS & STI Control Programme, Nairobi, Kenya. Francis Kundu and Vane Lumumba are with the National Council for Population and Development, Nairobi. Travis Lim is with the Centers for Disease Control and Prevention (CDC), Atlanta, GA. Tom Oluoch and Katherine A. Robinson are with the CDC, Nairobi
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Negin J, Nyirenda M, Seeley J, Mutevedzi P. Inequality in health status among older adults in Africa: the surprising impact of anti-retroviral treatment. J Cross Cult Gerontol 2014; 28:491-3. [PMID: 24122525 DOI: 10.1007/s10823-013-9215-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cairney LI, Kapilashrami A. Confronting ‘scale-down’: Assessing Namibia's human resource strategies in the context of decreased HIV/AIDS funding. Glob Public Health 2014; 9:198-209. [DOI: 10.1080/17441692.2014.881525] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Cailhol J, Craveiro I, Madede T, Makoa E, Mathole T, Parsons AN, Van Leemput L, Biesma R, Brugha R, Chilundo B, Lehmann U, Dussault G, Van Damme W, Sanders D. Analysis of human resources for health strategies and policies in 5 countries in Sub-Saharan Africa, in response to GFATM and PEPFAR-funded HIV-activities. Global Health 2013; 9:52. [PMID: 24160182 PMCID: PMC4016264 DOI: 10.1186/1744-8603-9-52] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 09/25/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Global Health Initiatives (GHIs), aiming at reducing the impact of specific diseases such as Human Immunodeficiency Virus (HIV), have flourished since 2000. Amongst these, PEPFAR and GFATM have provided a substantial amount of funding to countries affected by HIV, predominantly for delivery of antiretroviral therapy (ARV) and prevention strategies. Since the need for additional human resources for health (HRH) was not initially considered by GHIs, countries, to allow ARV scale-up, implemented short-term HRH strategies, adapted to GHI-funding conditionality. Such strategies differed from one country to another and slowly evolved to long-term HRH policies. The processes and content of HRH policy shifts in 5 countries in Sub-Saharan Africa were examined. METHODS A multi-country study was conducted from 2007 to 2011 in 5 countries (Angola, Burundi, Lesotho, Mozambique and South Africa), to assess the impact of GHIs on the health system, using a mixed methods design. This paper focuses on the impact of GFATM and PEPFAR on HRH policies. Qualitative data consisted of semi-structured interviews undertaken at national and sub-national levels and analysis of secondary data from national reports. Data were analysed in order to extract countries' responses to HRH challenges posed by implementation of HIV-related activities. Common themes across the 5 countries were selected and compared in light of each country context. RESULTS In all countries successful ARV roll-out was observed, despite HRH shortages. This was a result of mostly short-term emergency response by GHI-funded Non-Governmental Organizations (NGOs) and to a lesser extent by governments, consisting of using and increasing available HRH for HIV tasks. As challenges and limits of short-term HRH strategies were revealed and HIV became a chronic disease, the 5 countries slowly implemented mid to long-term HRH strategies, such as formalisation of pilot initiatives, increase in HRH production and mitigation of internal migration of HRH, sometimes in collaboration with GHIs. CONCLUSION Sustainable HRH strengthening is a complex process, depending mostly on HRH production and retention factors, these factors being country-specific. GHIs could assist in these strategies, provided that they are flexible enough to incorporate country-specific needs in terms of funding, that they coordinate at global-level and minimise conditionality for countries.
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Affiliation(s)
- Johann Cailhol
- School of Public Health, Faculty of Community Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Isabel Craveiro
- Unit of International Public Health and Biostatistics, Instituto de Higiene e Medicina Tropical, CMDT, WHO Collaborating Centre for Health Workforce Policy and Planning, Universidade Nova de Lisboa, Lisbon, Portugal
| | | | - Elsie Makoa
- Faculty of Health Sciences, National University of Lesotho, Maseru, Lesotho
| | - Thubelihle Mathole
- School of Public Health, Faculty of Community Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Ann Neo Parsons
- School of Public Health, Faculty of Community Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Luc Van Leemput
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Regien Biesma
- Department of Epidemiology and Public Health Medicine, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Ruairi Brugha
- Department of Epidemiology and Public Health Medicine, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | | | - Uta Lehmann
- School of Public Health, Faculty of Community Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Gilles Dussault
- Unit of International Public Health and Biostatistics, Instituto de Higiene e Medicina Tropical, CMDT, WHO Collaborating Centre for Health Workforce Policy and Planning, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - David Sanders
- School of Public Health, Faculty of Community Health Sciences, University of the Western Cape, Cape Town, South Africa
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Nutman S, McKee D, Khoshnood K. Externalities of prevention of mother-to-child transmission programs: a systematic review. AIDS Behav 2013; 17:445-60. [PMID: 22711224 DOI: 10.1007/s10461-012-0228-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There has been considerable debate about the effects of targeted global health assistance in low- and middle-income countries on health systems, specifically HIV/AIDS funding. Recently, a handful of studies have emerged that describe the implementation of PMTCT programs, which have many theoretical links to maternal and child health. Through a systematic review of research published between January 2000 and March 2011, this paper synthesizes evidence evaluating the impact of these programs. We assessed 5,855 papers, reviewed 154, and included 21 articles. They offer evidence of beneficial synergies between PMTCT programs and both STI prevention and early childhood immunization. Other data, including information about antenatal and delivery care, family planning, and nutrition supplementation varied considerably across studies demonstrating both positive and negative effects of PMTCT. More research is needed to allow countries and funders to make informed decisions regarding allocation of limited funds to targeted versus broad categories of health care.
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Affiliation(s)
- Sarah Nutman
- College of Arts and Sciences, Yale University, New Haven, CT, USA
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Kruk ME, Jakubowski A, Rabkin M, Elul B, Friedman M, El-Sadr W. PEPFAR programs linked to more deliveries in health facilities by African women who are not infected with HIV. Health Aff (Millwood) 2012; 31:1478-88. [PMID: 22778337 DOI: 10.1377/hlthaff.2012.0197] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
HIV programs in lower-income countries have provided lifesaving care and treatment to millions of people, but their expansion has raised concerns that these programs may have diverted health workers, management attention, and infrastructure investments from other health priorities, such as high maternal mortality in sub-Saharan Africa. We assessed the effect of HIV programs supported by the President's Emergency Plan for AIDS Relief (PEPFAR) on maternal health services for women not infected with HIV in 257 health facilities in eight African countries in 2007-11. Controlling for other variables, we found that having more patients on antiretroviral treatment and HIV-related infrastructure investments, such as on-site laboratories at health clinics, were associated with more deliveries at health facilities by women not infected with HIV. This association is consistent with the hypothesis that PEPFAR-funded infrastructure may also support other health services and that the program may have laid the foundation for improving health system performance in maternal health overall. We recommend that lessons learned from the rapid expansion of HIV services in sub-Saharan Africa should be drawn on to increase the provision of maternal and newborn health care and other high-priority health services, such as the treatment of diabetes, hypertension, and other chronic, noncommunicable diseases.
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Affiliation(s)
- Margaret E Kruk
- Columbia University Mailman School of Public Health, New York, NY, USA.
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20
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PEPFAR, health system strengthening, and promoting sustainability and country ownership. J Acquir Immune Defic Syndr 2012; 60 Suppl 3:S113-9. [PMID: 22797732 DOI: 10.1097/qai.0b013e31825d28d7] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Evidence demonstrates that scale-up of HIV services has produced stronger health systems and, conversely, that stronger health systems were critical to the success of the HIV scale-up. Increased access to and effectiveness of HIV treatment and care programs, attention to long-term sustainability, and recognition of the importance of national governance, and country ownership of HIV programs have resulted in an increased focus on structures that compromise the broader health system. Based on a review published literature and expert opinion, the article proposes 4 key health systems strengthening issues as a means to promote sustainability and country ownership of President's Emergency Plan for AIDS Relief and other global health initiatives. First, development partners need provide capacity building support and to recognize and align resources with national government health strategies and operational plans. Second, investments in human capital, particularly human resources for health, need to be guided by national institutions and supported to ensure the training and retention of skilled, qualified, and relevant health care providers. Third, a range of financing strategies, both new resources and improved efficiencies, need to be pursued as a means to create more fiscal space to ensure sustainable and self-reliant systems. Finally, service delivery models must adjust to recent advancements in areas of HIV prevention and treatment and aim to establish evidence-based delivery models to reduce HIV transmission rates and the overall burden of disease. The article concludes that there needs to be ongoing efforts to identify and implement strategic health systems strengthening interventions and address the inherent tension and debate over investments in health systems.
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Shepard DS, Zeng W, Amico P, Rwiyereka AK, Avila-Figueroa C. A controlled study of funding for human immunodeficiency virus/acquired immunodeficiency syndrome as resource capacity building in the health system in Rwanda. Am J Trop Med Hyg 2012; 86:902-907. [PMID: 22556094 PMCID: PMC3335700 DOI: 10.4269/ajtmh.2012.11-0202] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Because human inmmunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) receives more donor funding globally than that for all other diseases combined, some critics allege this support undermines general health care. This empirical study evaluates the impact of HIV/AIDS funding on the primary health care system in Rwanda. Using a quasi-experimental design, we randomly selected 25 rural health centers (HCs) that started comprehensive HIV/AIDS services from 2002 through 2006 as the intervention group. Matched HCs with no HIV/AIDS services formed the control group. The analysis compared growth in inputs and services between intervention and control HCs with a difference-in-difference analysis in a random-effects model. Intervention HCs performed better than control HCs in most services (seven of nine), although only one of these improvements (Bacille Calmette-Guérin vaccination) reached or approached statistical significance. In conclusion, this six-year controlled study found no adverse effects of the expansion of HIV/AIDS services on non-HIV services among rural health centers in Rwanda.
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Affiliation(s)
- Donald S. Shepard
- *Address correspondence to Donald S. Shepard, Schneider Institutes for Health Policy, Heller School, MS 035, Brandeis University, Waltham, MA 02454-9110. E-mail:
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Abstract
Global AIDS programs such as the US President's Emergency Plan for AIDS Relief (PEPFAR) face a challenging health care management transition. HIV care must evolve from vertically-organized, externally-supported efforts to sustainable, locally controlled components that are integrated into the horizontal primary health care systems of host nations. We compared four southern African nations in AIDS care, financial, literacy, and health worker capacity parameters (2005 to 2009) to contrast in their capacities to absorb the huge HIV care and prevention endeavors that are now managed with international technical and fiscal support. Botswana has a relatively high national income, a small population, and an advanced HIV/AIDS care program; it is well poised to take on management of its HIV/AIDS programs. South Africa has had a slower start, given HIV denialism philosophies of the previous government leadership. Nonetheless, South Africa has the national income, health care management, and health worker capacity to succeed in fully local management. The sheer magnitude of the burden is daunting, however, and South Africa will need continuing fiscal assistance. In contrast, Zambia and Mozambique have comparatively lower per capita incomes, many fewer health care workers per capita, and lower national literacy rates. It is improbable that fully independent management of their HIV programs is feasible on the timetable being contemplated by donors, nor is locally sustainable financing conceivable at present. A tailored nation-by-nation approach is needed for the transition to full local capacitation; donor nation policymakers must ensure that global resources and technical support are not removed prematurely.
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van den Akker T, Bemelmans M, Ford N, Jemu M, Diggle E, Scheffer S, Zulu I, Akesson A, Shea J. HIV care need not hamper maternity care: a descriptive analysis of integration of services in rural Malawi. BJOG 2012; 119:431-8. [PMID: 22251303 DOI: 10.1111/j.1471-0528.2011.03229.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the use of reproductive health care and incidence of paediatric HIV infection during the expansion of antiretroviral therapy and services for the prevention of mother-to-child transmission in rural Malawi, and the influence of integration of these HIV-related services into general health services. DESIGN Descriptive analysis. SETTING Thyolo District, with a population of 600,000, an HIV prevalence of 21% and a total fertility rate of 5.7 in 2004. POPULATION Women attending reproductive health services care in 2005 and 2010. METHODS Review of facility records and databases for routine monitoring. MAIN OUTCOME MEASURES Use of antenatal, intrapartum, postpartum, family planning and sexually transmitted infection services; incidence of HIV infection in infants born to mothers who received prevention of mother-to-child transmission care. RESULTS There was a marked increase in the uptake of perinatal care: pregnant women in 2010 were 50% more likely to attend at least one antenatal visit (RR 1.50, 95% CI 1.48-1.51); were twice as likely to deliver at a healthcare facility (RR 2.05, 95% CI 2.01-2.08); and were more than four times as likely to present for postpartum care (RR 4.40, 95% CI 4.25-4.55). Family planning consultations increased by 40% and the number of women receiving treatment for sexually transmitted infections doubled. Between 2007 and 2010, the number of HIV-exposed infants who underwent testing for HIV went up from 421 to 1599/year, and the proportion testing positive decreased from 13.3 to 5.0%; infants were 62% less likely to test HIV positive (RR 0.38, 95% CI 0.27-0.52). CONCLUSIONS During the expansion and integration of HIV care, the use of reproductive health services increased and the outcomes of infants born to HIV-infected mothers improved. HIV care may be successfully integrated into broader reproductive health services.
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Affiliation(s)
- T van den Akker
- Thyolo District Health Office, Ministry of Health, Thyolo, Malawi.
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Brewster D. Science and ethics of human immunodeficiency virus/acquired immunodeficiency syndrome controversies in Africa. J Paediatr Child Health 2011; 47:646-55. [PMID: 21951451 DOI: 10.1111/j.1440-1754.2011.02179.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic in Africa has raised important ethical issues for both researchers and clinicians. The most notorious controversy has been related to the zidovudine (AZT) trials in Africa in the late 1990s, in which the control groups were given a placebo rather than an effective drug to prevent vertical transmission. This raised concerns in the sponsoring country about exploitation of subjects, injustice and an ethical double standard between donor countries and resource-poor settings. However, the real double standard is between clinical practice standards in Western versus African countries, which must be addressed as part of the increasing global inequity of wealth both between countries and also within countries. There are important limitations to ethical declarations, principles and guidelines on their own without contextual ethical reasoning. The focus on research ethics with the HIV epidemic has led to a relative neglect of ethical issues in clinical practice. Although the scientific advances in HIV/AIDS have changed the ethical issues since the 1990s, there has also been progress in the bioethics of HIV/AIDS in terms of ethical review capability by local committees as well as in exposure to ethical issues by clinicians and researchers in Africa. However, serious concerns remain about the overregulation of research by bureaucratic agencies which could discourage African research on specifically African health issues. There is also a need for African academic institutions and researchers to progressively improve their research capacity with the assistance of research funders and donor agencies.
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Affiliation(s)
- David Brewster
- School of Medicine, University of Botswana, Gaborone, Botswana.
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Larson E, O'Bra H, Brown JW, Goldman T, Pillay Y, Klausner JD. Equitable distribution of PEPFAR-supported HIV/AIDS services in South Africa. Am J Public Health 2011; 101:1349-51; author reply 1351. [PMID: 21680922 DOI: 10.2105/ajph.2011.300242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Walsh A, Ndubani P, Simbaya J, Dicker P, Brugha R. Task sharing in Zambia: HIV service scale-up compounds the human resource crisis. BMC Health Serv Res 2010; 10:272. [PMID: 20849626 PMCID: PMC2955013 DOI: 10.1186/1472-6963-10-272] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 09/17/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Considerable attention has been given by policy makers and researchers to the human resources for health crisis in Africa. However, little attention has been paid to quantifying health facility-level trends in health worker numbers, distribution and workload, despite growing demands on health workers due to the availability of new funds for HIV/AIDS control scale-up. This study analyses and reports trends in HIV and non-HIV ambulatory service workloads on clinical staff in urban and rural district level facilities. METHODS Structured surveys of health facility managers, and health services covering 2005-07 were conducted in three districts of Zambia in 2008 (two urban and one rural), to fill this evidence gap. Intra-facility analyses were conducted, comparing trends in HIV and non-HIV service utilisation with staff trends. RESULTS Clinical staff (doctors, nurses and nurse-midwives, and clinical officers) numbers and staff population densities fell slightly, with lower ratios of staff to population in the rural district. The ratios of antenatal care and family planning registrants to nurses/nurse-midwives were highest at baseline and increased further at the rural facilities over the three years, while daily outpatient department (OPD) workload in urban facilities fell below that in rural facilities. HIV workload, as measured by numbers of clients receiving antiretroviral treatment (ART) and prevention of mother to child transmission (PMTCT) per facility staff member, was highest in the capital city, but increased rapidly in all three districts. The analysis suggests evidence of task sharing, in that staff designated by managers as ART and PMTCT workers made up a higher proportion of frontline service providers by 2007. CONCLUSIONS This analysis of workforce patterns across 30 facilities in three districts of Zambia illustrates that the remarkable achievements in scaling-up HIV/AIDS service delivery has been on the back of sustained non-HIV workload levels, increasing HIV workload and stagnant health worker numbers. The findings are based on an analysis of routine data that are available to district and national managers. Mixed methods research is needed, combining quantitative analyses of routine health information with follow-up qualitative interviews, to explore and explain workload changes, and to identify and measure where problems are most acute, so that decision makers can respond appropriately. This study provides quantitative evidence of a human resource crisis in health facilities in Zambia, which may be more acute in rural areas.
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Affiliation(s)
- Aisling Walsh
- Department of Epidemiology and Public Health Medicine, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Phillimon Ndubani
- Institute of Economic and Social Research, University of Zambia, Lusaka, Zambia
| | - Joseph Simbaya
- Institute of Economic and Social Research, University of Zambia, Lusaka, Zambia
| | - Patrick Dicker
- Department of Epidemiology and Public Health Medicine, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ruairí Brugha
- Department of Epidemiology and Public Health Medicine, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Global Health Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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