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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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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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Sakala JJ, Chimatiro CS, Salima R, Kapachika A, Kalepa J, Stones W. The Integration of vertical and horizontal programmes for health systems strengthening in Malawi: a case study. Malawi Med J 2022; 34:206-212. [PMID: 36406101 PMCID: PMC9641613 DOI: 10.4314/mmj.v34i3.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
A challenge for the health system in Malawi is that funding allocation is heavily influenced by donor priorities. As a result, mandated routine elements of service delivery may not be fully offered owing to lack of resources or programmatic priority. Integration of currently active 'vertical' programmes (those focused on a specific priority disease entity) into existing 'horizontal' services (meaning provision across the range of clinical and public health need) has potential to improve access and quality of service delivery for Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) in Malawi. We identified and tabulated the main vertical funding streams currently available in Malawi and identified where these could intersect with existing horizontal health sector programmes in order to strengthen RMNCAH. We have indicated how each of the main vertical programmatic components can be adapted and integrated to support broader system strengthening within RMNCAH focusing especially on drug and commodity procurement, supply chain logistics, health facility and equipment maintenance/upgrading, health service activity data systems, human resources for 'front line' RMNCAH provision, as well as community engagement and mobilization. By circumventing the various limitations of vertical programmes in the delivery of health services in the country, they would complement existing funding streams rather than operating in a vacuum as independent activities. We therefore recommend the integration of horizontal and existing vertical programmes in order to improve RMNCAH in Malawi.
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Affiliation(s)
- Joseph J Sakala
- School of Public Health and Family Medicine, College of Medicine, University of Malawi
| | - Chancy S Chimatiro
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Africa Center of Excellence in Public Health (ACEPHEM), University of Malawi, College of Medicine, Blantyre, Malawi
| | - Racheal Salima
- School of Public Health and Family Medicine, College of Medicine, University of Malawi
| | - Arnold Kapachika
- School of Public Health and Family Medicine, College of Medicine, University of Malawi
| | - Josephine Kalepa
- School of Public Health and Family Medicine, College of Medicine, University of Malawi
| | - William Stones
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Centre for Reproductive Health, College of Medicine, University of Malawi
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Bandawe G, Chitenje M, Bitiliyu-Bangoh J, Kampira E. Approaches to Deployment of Molecular Testing for SARS-CoV-2 in Resource-Limited Settings. Clin Lab Med 2022; 42:283-298. [PMID: 35636827 PMCID: PMC8885302 DOI: 10.1016/j.cll.2022.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Deployment of molecular testing for SARS-CoV-2 in resource-limited settings is challenging. Scale-up of molecular had to be conducted with a laboratory system strengthening approach that emphasize laboratory integration. National reference laboratories play a central role. In Malawi the molecular testing was underpinned by existing pathogen control programs for human immunodeficiency virus and tuberculosis that use Abbott and GeneXpert machines and reagents. Despite this, the impact on these programs was well managed. Antigen testing increased access to testing. Pooled testing and direct-to-polymerase chain reaction methods have the potential to save costs and further increase access to molecular tests.
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Affiliation(s)
- Gama Bandawe
- Biological Sciences Department, Academy of Medical Sciences, Malawi University of Science and Technology, P. O. Box 5196, Limbe, Malawi.
| | - Moses Chitenje
- International Teaching and Education Centre for Health (ITECH), PO Box 30369, Capital City Lilongwe 3, Plot 13/14, 1st Floor ARWA House, City Center, Lilongwe, Malawi; Public Health Institute of Malawi, Ministry of Health, Lilongwe, Malawi
| | | | - Elizabeth Kampira
- Centres for Disease Control and Prevention, P. O. Box 30016, NICO House, City Centre, Lilongwe 3, Lilongwe, Malawi
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Choi Y, Ibrahim S, Park LP, Cohen CR, Bukusi EA, Huchko MJ. Uptake and correlates of cervical cancer screening among women attending a community-based multi-disease health campaign in Kenya. BMC Womens Health 2022; 22:122. [PMID: 35436908 PMCID: PMC9014598 DOI: 10.1186/s12905-022-01702-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/16/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Despite the increased risk of cervical cancer among HIV-positive women, many HIV-care programs do not offer integrated cervical cancer screening. Incorporating self-collected Human Papillomavirus (HPV) testing into HIV programs is a potential strategy to identify women at higher risk for cervical cancer while leveraging the staffing, infrastructure and referral systems for existing services. Community-based HIV and HPV testing has been effective and efficient when offered in single-disease settings. METHODS This cross-sectional study was conducted within a community outreach and multi-disease screening campaigns organized by the Family AIDS Care and Education Services in Kisumu County, Kenya. In addition to HIV testing, the campaigns provided screening for TB, malaria, hypertension, diabetes, and referrals for voluntary medical male circumcision. After these services, women aged 25-65 were offered self-collected HPV testing. Rates and predictors of cervical cancer screening uptake and of HPV positivity were analyzed using tabular analysis and Fisher's Exact Test. Logistic regression was performed to explore multivariate associations with screening uptake. RESULTS Among the 2016 women of screening age who attended the outreach campaigns, 749 women (35.6%) were screened, and 134 women (18.7%) were HPV-positive. In bivariate analysis, women who had no children (p < 0.01), who were not pregnant (p < 0.01), who were using contraceptives (p < 0.01), who had sex without using condoms (p < 0.05), and who were encouraged by a family member other than their spouse (p < 0.01), were more likely to undergo screening. On multivariable analysis, characteristics associated with higher screening uptake included: women aged 45-54 (OR 1.62, 95% CI 1.05-2.52) compared to women aged 25-34; no children (OR 1.65, 95% CI 1.06-2.56); and family support other than their spouse (OR 1.53, 95% CI 1.09-2.16). Women who were pregnant were 0.44 times (95% CI 0.25-0.76) less likely to get screened. Bivariate analyses with participant characteristics and HPV positivity found that women who screened HPV-positive were more likely to be HIV-positive (p < 0.001) and single (p < 0.001). CONCLUSIONS The low screening uptake may be attributed to implementation challenges including long waiting times for service at the campaign and delays in procuring HPV test kits. However, given the potential benefits of integrating HPV testing into HIV outreach campaigns, these challenges should be examined to develop more effective multi-disease outreach interventions.
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Affiliation(s)
- Yujung Choi
- Duke Global Health Institute, Duke University, Durham, NC, USA.
| | | | - Lawrence P Park
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, San Francisco, CA, USA
| | | | - Megan J Huchko
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
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Kiplagat J, Tran DN, Barber T, Njuguna B, Vedanthan R, Triant VA, Pastakia SD. How health systems can adapt to a population ageing with HIV and comorbid disease. Lancet HIV 2022; 9:e281-e292. [PMID: 35218734 DOI: 10.1016/s2352-3018(22)00009-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 06/14/2023]
Abstract
As people age with HIV, their needs increase beyond solely managing HIV care. Ageing people with HIV, defined as people with HIV who are 50 years or older, face increased risk of both age-regulated comorbidities and ageing-related issues. Globally, health-care systems have struggled to meet these changing needs of ageing people with HIV. We argue that health systems need to rethink care strategies to meet the growing needs of this population and propose models of care that meet these needs using the WHO health system building blocks. We focus on care provision for ageing people with HIV in the three different funding mechanisms: President's Emergency Plan for AIDS Relief and Global Fund funded nations, the USA, and single-payer government health-care systems. Although our categorisation is necessarily incomplete, our efforts provide a valuable contribution to the debate on health systems strengthening as the need for integrated, people-centred, health services increase.
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Affiliation(s)
| | - Dan N Tran
- Academic Model Providing Access to Healthcare, Eldoret, Kenya; Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, PA, USA
| | - Tristan Barber
- Department of HIV Medicine, Ian Charleson Day Centre, Royal Free Hospital, London, UK
| | - Benson Njuguna
- Academic Model Providing Access to Healthcare, Eldoret, Kenya; Department of Clinical Pharmacy and Practice, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Rajesh Vedanthan
- Academic Model Providing Access to Healthcare, Eldoret, Kenya; Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Virginia A Triant
- Divisions of Infectious Diseases and General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sonak D Pastakia
- Academic Model Providing Access to Healthcare, Eldoret, Kenya; Center for Health Equity and Innovation, College of Pharmacy, Purdue University, Indianapolis, IN, USA.
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McCombe G, Murtagh S, Lazarus JV, Van Hout MC, Bachmann M, Jaffar S, Garrib A, Ramaiya K, Sewankambo NK, Mfinanga S, Cullen W. Integrating diabetes, hypertension and HIV care in sub-Saharan Africa: a Delphi consensus study on international best practice. BMC Health Serv Res 2021; 21:1235. [PMID: 34781929 PMCID: PMC8591882 DOI: 10.1186/s12913-021-07073-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 09/16/2021] [Indexed: 11/25/2022] Open
Abstract
Background Although HIV continues to have a high prevalence among adults in sub-Saharan Africa (SSA), the burden of noncommunicable diseases (NCD) such as diabetes and hypertension is increasing rapidly. There is an urgent need to expand the capacity of healthcare systems in SSA to provide NCD services and scale up existing chronic care management pathways. The aim of this study was to identify key components, outcomes, and best practice in integrated service provision for the prevention, identification and treatment of HIV, hypertension and diabetes. Methods An international, multi stakeholder e-Delphi consensus study was conducted over two successive rounds. In Round 1, 24 participants were asked to score 27 statements, under the headings ‘Service Provision’ and ‘Benefits of Integration’, by importance. In Round 2, the 16 participants who completed Round 1 were shown the distribution of scores from other participants along with the score that they attributed to an outcome and were asked to reflect on the score they gave, based on the scores of the other participants and then to rescore if they wished to. Nine participants completed Round 2. Results Based on the Round 1 ranking, 19 of the 27 outcomes met the 70% threshold for consensus. Four additional outcomes suggested by participants in Round 1 were added to Round 2, and upon review by participants, 22 of the 31 outcomes met the consensus threshold. The five items participants scored from 7 to 9 in both rounds as essential for effective integrated healthcare delivery of health services for chronic conditions were improved data collection and surveillance of NCDs among people living with HIV to inform integrated NCD/HIV programme management, strengthened drug procurement systems, availability of equipment and access to relevant blood tests, health education for all chronic conditions, and enhanced continuity of care for patients with multimorbidity. Conclusions This study highlights the outcomes which may form key components of future complex interventions to define a model of integrated healthcare delivery for diabetes, hypertension and HIV in sub-Saharan Africa.
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Affiliation(s)
| | | | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | | | | | - Anupam Garrib
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Sayoki Mfinanga
- National Institute for Medical Research, Dar es Salaam, Tanzania
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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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Global, regional, and national sex-specific burden and control of the HIV epidemic, 1990-2019, for 204 countries and territories: the Global Burden of Diseases Study 2019. Lancet HIV 2021. [PMID: 34592142 PMCID: PMC8491452 DOI: 10.1016/s2352-3018(21)00152-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The sustainable development goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030. Understanding the current state of the HIV epidemic and its change over time is essential to this effort. This study assesses the current sex-specific HIV burden in 204 countries and territories and measures progress in the control of the epidemic. METHODS To estimate age-specific and sex-specific trends in 48 of 204 countries, we extended the Estimation and Projection Package Age-Sex Model to also implement the spectrum paediatric model. We used this model in cases where age and sex specific HIV-seroprevalence surveys and antenatal care-clinic sentinel surveillance data were available. For the remaining 156 of 204 locations, we developed a cohort-incidence bias adjustment to derive incidence as a function of cause-of-death data from vital registration systems. The incidence was input to a custom Spectrum model. To assess progress, we measured the percentage change in incident cases and deaths between 2010 and 2019 (threshold >75% decline), the ratio of incident cases to number of people living with HIV (incidence-to-prevalence ratio threshold <0·03), and the ratio of incident cases to deaths (incidence-to-mortality ratio threshold <1·0). FINDINGS In 2019, there were 36·8 million (95% uncertainty interval [UI] 35·1-38·9) people living with HIV worldwide. There were 0·84 males (95% UI 0·78-0·91) per female living with HIV in 2019, 0·99 male infections (0·91-1·10) for every female infection, and 1·02 male deaths (0·95-1·10) per female death. Global progress in incident cases and deaths between 2010 and 2019 was driven by sub-Saharan Africa (with a 28·52% decrease in incident cases, 95% UI 19·58-35·43, and a 39·66% decrease in deaths, 36·49-42·36). Elsewhere, the incidence remained stable or increased, whereas deaths generally decreased. In 2019, the global incidence-to-prevalence ratio was 0·05 (95% UI 0·05-0·06) and the global incidence-to-mortality ratio was 1·94 (1·76-2·12). No regions met suggested thresholds for progress. INTERPRETATION Sub-Saharan Africa had both the highest HIV burden and the greatest progress between 1990 and 2019. The number of incident cases and deaths in males and females approached parity in 2019, although there remained more females with HIV than males with HIV. Globally, the HIV epidemic is far from the UNAIDS benchmarks on progress metrics. FUNDING The Bill & Melinda Gates Foundation, the National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH.
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Mulderij-Jansen V, Gerstenbluth I, Duits A, Tami A, Bailey A. Evaluating and strengthening the health system of Curaҫao to improve its performance for future outbreaks of vector-borne diseases. Parasit Vectors 2021; 14:500. [PMID: 34565464 PMCID: PMC8474927 DOI: 10.1186/s13071-021-05011-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 09/12/2021] [Indexed: 11/29/2022] Open
Abstract
Background Vector-borne diseases (VBDs) such as dengue, chikungunya, and Zika pose a significant challenge to health systems in countries they affect, especially countries with less developed healthcare systems. Therefore, countries are encouraged to work towards more resilient health systems. This qualitative study aims to examine the performance of the health system of the Dutch Caribbean island of Curaҫao regarding the prevention and control of VBDs in the last decade by using the WHO health system building blocks. Methods From November 2018 to December 2020, a multi-method qualitative study was performed in Curaçao, applying content analysis of documents (n = 50), five focus group discussions (n = 30), interviews with experts (n = 11) and 15 observation sessions. The study was designed based on the WHO framework: health system building blocks. Two cycles of inductive and deductive coding were employed, and Nvivo software was used to analyse the data. Results This study’s data highlighted the challenges (e.g. insufficient oversight, coordination, leadership skills, structure and communication) that the departments of the health system of Curaҫao faced during the last three epidemics of VBDs (2010–2020). Furthermore, low levels of collaboration between governmental and non-governmental organisations (e.g. semi-governmental and private laboratories) and insufficient capacity building to improve skills (e.g. entomological, surveillance skills) were also observed. Lastly, we observed how bottlenecks in one building block negatively influenced other building blocks (e.g. inadequate leadership/governance obstructed the workforce's performance). Conclusions This study uncovers potential organisational bottlenecks that have affected the performance of the health system of Curaҫao negatively. We recommend starting with the reinforcement of oversight of the integrated vector management programme to ensure the development, implementation and evaluation of related legislation, policies and interventions. Also, we recommend evaluating and reforming the existing administrative and organisational structure of the health system by considering the cultural style, challenges and barriers of the current health system. More efforts are needed to improve the documentation of agreements, recruitment and evaluation of the workforce's performance. Based on our findings, we conceptualised actions to strengthen the health system's building blocks to improve its performance for future outbreaks of infectious diseases. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s13071-021-05011-x.
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Affiliation(s)
- Vaitiare Mulderij-Jansen
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. .,International Development Studies, Department of Human Geography and Spatial Planning, Faculty of Geosciences, Utrecht University, Utrecht, The Netherlands. .,Department of Epidemiology, Curaçao Biomedical & Health Research Institute, Willemstad, Curaçao.
| | - Izzy Gerstenbluth
- Department of Epidemiology, Curaçao Biomedical & Health Research Institute, Willemstad, Curaçao.,Epidemiology and Research Unit, Ministry of Health Environment and Nature of Curaçao, Willemstad, Curaçao
| | - Ashley Duits
- Red Cross Blood Bank Foundation, Willemstad, Curaçao.,Department of Immunology, Curaçao Biomedical & Health Research Institute, Willemstad, Curaçao
| | - Adriana Tami
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ajay Bailey
- International Development Studies, Department of Human Geography and Spatial Planning, Faculty of Geosciences, Utrecht University, Utrecht, The Netherlands
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Adeyemi O, Lyons M, Njim T, Okebe J, Birungi J, Nana K, Claude Mbanya J, Mfinanga S, Ramaiya K, Jaffar S, Garrib A. Integration of non-communicable disease and HIV/AIDS management: a review of healthcare policies and plans in East Africa. BMJ Glob Health 2021; 6:bmjgh-2020-004669. [PMID: 33947706 PMCID: PMC8098934 DOI: 10.1136/bmjgh-2020-004669] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 03/27/2021] [Accepted: 04/02/2021] [Indexed: 01/08/2023] Open
Abstract
Background Low-income and middle-income countries are struggling to manage growing numbers of patients with chronic non-communicable diseases (NCDs), while services for patients with HIV infection are well established. There have been calls for integration of HIV and NCD services to increase efficiency and improve coverage of NCD care, although evidence of effectiveness remains unclear. In this review, we assess the extent to which National HIV and NCD policies in East Africa reflect the calls for HIV-NCD service integration. Methods Between April 2018 and December 2020, we searched for policies, strategies and guidelines associated with HIV and NCDs programmes in Burundi, Kenya, Rwanda, South Sudan, Tanzania and Uganda. Documents were searched manually for plans for integration of HIV and NCD services. Data were analysed qualitatively using document analysis. Results Thirty-one documents were screened, and 13 contained action plans for HIV and NCDs service integration. Integrated delivery of HIV and NCD care is recommended in high level health policies and treatment guidelines in four countries in the East African region; Kenya, Rwanda, Tanzania and Uganda, mostly relating to integrating NCD care into HIV programmes. The increasing burden of NCDs, as well as a move towards person-centred differentiated delivery of services for people living with HIV, is a factor in the recent adoption of integrated HIV and NCD service delivery plans. Both South Sudan and Burundi report a focus on building their healthcare infrastructure and improving coverage and quality of healthcare provision, with no reported plans for HIV and NCD care integration. Conclusion Despite the limited evidence of effectiveness, some East African countries have already taken steps towards HIV and NCD service integration. Close monitoring and evaluation of the integrated HIV and NCD programmes is necessary to provide insight into the associated benefits and risks, and to inform future service developments.
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Affiliation(s)
- Olukemi Adeyemi
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Mary Lyons
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Tsi Njim
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Joseph Okebe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Kevin Nana
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Yaounde, Cameroon
| | - Jean Claude Mbanya
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Yaounde, Cameroon
| | - Sayoki Mfinanga
- Muhimbili Medical Research Centre, National Institute of Medical Research, Dar es Salaam, United Republic of Tanzania
| | - Kaushik Ramaiya
- Shree Hindu Mandal Hospital, Dar es Salaam, United Republic of Tanzania
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anupam Garrib
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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Identifying barriers and facilitators in HIV-indicator reporting for different health facility performances: A qualitative case study. PLoS One 2021; 16:e0247525. [PMID: 33630971 PMCID: PMC7906392 DOI: 10.1371/journal.pone.0247525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/09/2021] [Indexed: 12/03/2022] Open
Abstract
Identifying barriers and facilitators in HIV-indicator reporting contributes to strengthening HIV monitoring and evaluation efforts by acknowledging contributors to success, as well as identifying weaknesses within the system that require improvement. Nonetheless, there is paucity in identifying and comparing barriers and facilitators in HIV-indicator data reporting among facilities that perform well and those that perform poorly at meeting reporting completeness and timeliness requirements. Therefore, this study aims to use a qualitative approach in identifying and comparing the current state of barriers and facilitators in routine reporting of HIV-indicators by facilities performing well, and those performing poorly in meeting facility reporting completeness and timeliness requirements to District Health Information Software2 (DHIS2). A multiple qualitative case study design was employed. The criteria for case selection was based on performance in HIV-indicator facility reporting completeness and timeliness. Areas of interest revolved around reporting procedures, organizational, behavioral, and technical factors. Purposive sampling was used to identify key informants in the study. Data was collected using semi-structured in-depth interviews with 13 participants, and included archival records on facility reporting performance, looking into documentation, and informal direct observation at 13 facilities in Kenya. Findings revealed that facilitators and barriers in reporting emerged from the following factors: interrelationship between workload, teamwork and skilled personnel, role of an EMRs system in reporting, time constraints, availability and access-rights to DHIS2, complexity of reports, staff rotation, availability of trainings and mentorship, motivation, availability of standard operating procedures and resources. There was less variation in barriers and facilitators faced by facilities performing well and those performing poorly. Continuous evaluations have been advocated within health information systems literature. Therefore, continuous qualitative assessments are also necessary in order to determine improvements and recurring of similar issues. These assessments have also complemented other quantitative analyses related to this study.
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Asiimwe SB, Farrell M, Kobayashi LC, Manne-Goehler J, Kahn K, Tollman SM, Kabudula CW, Gómez-Olivé FX, Wagner RG, Montana L, Berkman LF, Glymour MM, Bärnighausen T. Cognitive differences associated with HIV serostatus and antiretroviral therapy use in a population-based sample of older adults in South Africa. Sci Rep 2020; 10:16625. [PMID: 33024208 PMCID: PMC7539005 DOI: 10.1038/s41598-020-73689-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 09/15/2020] [Indexed: 12/29/2022] Open
Abstract
Previous clinical studies have reported adverse cognitive outcomes for people living with HIV (PLWH), but there are no population-based studies comparing cognitive function between older PLWH and comparators without HIV in sub-Saharan Africa. We analyzed baseline data of 40 + years-old participants in "Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa" (HAALSI) cohort. We measured cognition using a battery of conventional instruments assessing orientation, immediate- and delayed-recall, and numeracy (N = 4560), and the Oxford Cognitive Screen [OCS]-Plus, a novel instrument for low-literacy populations, assessing memory, language, visual-spatial ability, and executive functioning (N = 1997). Linear regression models comparing cognitive scores between participants with and without HIV were adjusted for sex, education, age, country of birth, father's occupation, ever-consumed alcohol, and asset index. PLWH scored on average 0.06 (95% CI 0.01-0.12) standard deviation (SD) units higher on the conventional cognitive function measure and 0.02 (95% CI - 0.07 to 0.04) SD units lower on the OCS-Plus measure than HIV-negative participants. We found higher cognitive function scores for PLWH compared to people without HIV when using a conventional measure of cognitive function but not when using a novel instrument for low-literacy settings.
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Affiliation(s)
- Stephen B Asiimwe
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th St., Mission Hall, 2nd Floor, San Francisco, CA, USA.
| | - Meagan Farrell
- Havard Center for Population and Development Studies, Harvard University, Cambridge, MA, USA
| | - Lindsay C Kobayashi
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Jen Manne-Goehler
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kathleen Kahn
- INDEPTH Network, Accra, Ghana
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephen M Tollman
- INDEPTH Network, Accra, Ghana
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Chodziwadziwa Whiteson Kabudula
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - F Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ryan G Wagner
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Livia Montana
- Havard Center for Population and Development Studies, Harvard University, Cambridge, MA, USA
| | - Lisa F Berkman
- Havard Center for Population and Development Studies, Harvard University, Cambridge, MA, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - M Maria Glymour
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th St., Mission Hall, 2nd Floor, San Francisco, CA, USA
| | - Till Bärnighausen
- Havard Center for Population and Development Studies, Harvard University, Cambridge, MA, USA
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, University of Heidelberg, Baden-Württemberg, Germany
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Doshi M, Macharia P, Mathenge J, Musyoki H, Amico KR, Battacharjee P, Blanchard J, Reza-Paul S, McKinnon LR, Kimani J, Lorway RR. Beyond biomedical and comorbidity approaches: Exploring associations between affinity group membership, health and health seeking behaviour among MSM/MSW in Nairobi, Kenya. Glob Public Health 2020; 15:968-984. [PMID: 32172670 DOI: 10.1080/17441692.2020.1739729] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We explored general health and psychosocial characteristics among male sex workers and other men who have sex with men in Nairobi, Kenya. A total of 595 MSM/MSW were recruited into the study. We assessed group differences among those who self-reported HIV positive (SR-HIVP) and those who self-reported HIV negative (SR-HIVN) and by affinity group membership. Quality of life among SR-HIVP participants was significantly worse compared to SR-HIVN participants. Independent of HIV status and affinity group membership, participants reported high levels of hazardous alcohol use, harmful substance use, recent trauma and childhood abuse. The overall sample exhibited higher prevalence of moderate to severe depressive symptoms compared to the general population. Quality of life among participants who did not report affinity group membership (AGN) was significantly worse compared to participants who reported affinity group membership (AGP). AGN participants also reported significantly lower levels of social support. Membership in affinity groups was found to influence health seeking behaviour. Our findings suggest that we need to expand the mainstay biomedical and comorbidity focused research currently associated with MSM/MSW. Moreover, there are benefits to being part of MSM/MSW organisations and these organisations can potentially play a vital role in the health and well-being of MSM/MSW.
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Affiliation(s)
- Monika Doshi
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Pascal Macharia
- Health Options for Young Men on HIV/AIDS/STI (HOYMAS), Nairobi, Kenya
| | - John Mathenge
- Health Options for Young Men on HIV/AIDS/STI (HOYMAS), Nairobi, Kenya
| | - Helgar Musyoki
- National AIDS and STI Control Programme, Ministry of Health, Government of Kenya, Nairobi, Kenya
| | - K Rivet Amico
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Parinita Battacharjee
- The Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - James Blanchard
- The Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Sushena Reza-Paul
- The Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Lyle R McKinnon
- Department of Medical Microbiology, University of Manitoba, Winnipeg, Canada.,Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.,Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Joshua Kimani
- Department of Medical Microbiology, University of Manitoba, Winnipeg, Canada.,Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Robert R Lorway
- The Centre for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
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15
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Mangona L, Brasil IA, Borges JP, Prista A, Farinatti P. Physical activity among women of low socioeconomic status living with HIV in two major cities of Brazil and Mozambique: A cross-sectional comparative study. Clinics (Sao Paulo) 2020; 75:e1771. [PMID: 32876111 PMCID: PMC7442379 DOI: 10.6061/clinics/2020/e1771] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 06/09/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Physical activity (PA) may reduce cardiovascular risk and preserve functional capacity of people living with human immunodeficiency virus (HIV). However, only limited research objectively measured PA in patients with low socioeconomic status (SES) in low-income countries, particularly in South America and sub-Saharan Africa. This study compared the PA assessed by accelerometers in women of low SES living with HIV under common antiretroviral therapy (cART) from two major cities in Brazil (Rio de Janeiro, n=33; 40.1±6.1 years) and Mozambique (Maputo, n=50; 38.8±8.7 years). METHODS Eligible women wore triaxial accelerometers during seven consecutive days, to estimate their habitual PA and daily energy expenditure. RESULTS The proportion of participants with overweight/obesity was greater in Rio than Maputo (57% vs. 30%; p=0.021), as well as those classified as sedentary based on steps/day (45% vs. 22%; p=0.02). Sedentary time was prevalent (Median±IQD: Rio-1236±142 vs. Maputo-1192±135 min/day; p=0.15). Time spent in PA was short, but Brazilians exhibited lower amount of light (111±56 vs. 145±51 min/day; p<0.001) and moderate-to-vigorous PA (88±3 vs. 64±36 min/day; p=0.001) vs. Mozambicans. The proportion of patients performing 60 min/day of moderate-to-vigorous PA were 58% (Rio) and 82% (Maputo), respectively. Despite of this, estimated daily energy expenditure was equivalent in both groups (1976±579 vs. 1933±492 kcal; p=0.731). CONCLUSIONS Women with low SES living with HIV in Maputo were more active vs. patients from Rio de Janeiro. Albeit sedentary behavior was prevalent, the proportion of patients complying with the minimum recommended PA for health was higher than values usually reported in developed countries.
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Affiliation(s)
- Lucília Mangona
- Laboratorio de Atividade Fisica e Promocao da Saude (LABSAU), Instituto de Educacao Fisica e Desportos, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, BR
| | - Iedda Almeida Brasil
- Laboratorio de Atividade Fisica e Promocao da Saude (LABSAU), Instituto de Educacao Fisica e Desportos, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, BR
| | - Juliana Pereira Borges
- Laboratorio de Atividade Fisica e Promocao da Saude (LABSAU), Instituto de Educacao Fisica e Desportos, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, BR
| | - Antonio Prista
- Universidade Pedagogica de Mozambique, Maputo, Mozambique
| | - Paulo Farinatti
- Laboratorio de Atividade Fisica e Promocao da Saude (LABSAU), Instituto de Educacao Fisica e Desportos, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, BR
- *Corresponding author. E-mail:
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Pathways to care and outcomes among hospitalised HIV-seropositive persons with cryptococcal meningitis in South Africa. PLoS One 2019; 14:e0225742. [PMID: 31830060 PMCID: PMC6907845 DOI: 10.1371/journal.pone.0225742] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/11/2019] [Indexed: 01/08/2023] Open
Abstract
Introduction Cryptococcus causes 15% of AIDS-related deaths and in South Africa, with its high HIV burden, is the dominant cause of adult meningitis. Cryptococcal meningitis (CM) mortality is high, partly because patients enter care with advanced HIV disease and because of failure of integrated care following CM diagnosis. We evaluated pathways to hospital care, missed opportunities for HIV testing and initiation of care. Methods We performed a cross-sectional study at five public-sector urban hospitals. We enrolled adults admitted with a first or recurrent episode of cryptococcal meningitis. Study nurses conducted interviews, supplemented by a prospective review of medical charts and laboratory records. Results From May to October 2015, 102 participants were enrolled; median age was 40 years (interquartile range [IQR] 33.9–46.7) and 56 (55%) were male. In the six weeks prior to admission, 2/102 participants were asymptomatic, 72/100 participants sought care at a public-sector facility, 16/100 paid for private health care. The median time from seeking care to admission was 4 days (IQR, 0–27 days). Of 94 HIV-seropositive participants, only 62 (66%) knew their status and 41/62 (66%) had ever taken antiretroviral treatment. Among 13 participants with a known previous CM episode, none were taking fluconazole maintenance therapy. In-hospital management was mostly amphotericin B; in-hospital mortality was high (28/92, 30%). Sixty-four participants were discharged, 92% (59/64) on maintenance fluconazole, 4% (3/64) not on fluconazole and 3% (2/64) unknown. Twelve weeks post-discharge, 31/64 (48%) participants were lost to follow up. By 12 weeks post discharge 7/33 (21%) had died. Interviewed patients were asked if they were still on fluconazole, 11% (2/18) were not. Conclusions Among hospitalised participants with CM, there were many missed opportunities for HIV care and linkage to ART prior to admission. Universal reflex CrAg screening may prompt earlier diagnosis of cryptococcal meningitis but there is a wider problem of timely linkage to care for HIV-seropositive people.
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Zakumumpa H, Bennett S, Ssengooba F. Leveraging the lessons learned from financing HIV programs to advance the universal health coverage (UHC) agenda in the East African Community. Glob Health Res Policy 2019; 4:27. [PMID: 31535036 PMCID: PMC6743123 DOI: 10.1186/s41256-019-0118-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/26/2019] [Indexed: 02/02/2023] Open
Abstract
Background Although there is broad consensus around the need to accelerate progress towards universal health coverage (UHC) in Sub-Saharan Africa, the financing strategies for achieving it are still unclear. We sought to leverage the lessons learned in financing HIV programs over the past two decades to inform efforts to advance the universal health coverage agenda in the East African Community. Methods We conducted a literature review of studies reporting financing mechanisms for HIV programs between 2004 and 2014. This review is further underpinned by evidence from a mixed-methods study entailing a survey of 195 health facilities across Uganda supplemented with 18 semi-structured interviews with HIV service managers. Results Our data shows that there are six broad HIV financing strategies with potential for application to the universal health coverage agenda in the East African Community (EAC); i) Bi-lateral and multi-lateral funding vehicles: The establishment of HIV-specific global financing vehicles such as PEPFAR and The Global Fund heralded an era of unprecedented levels of international funding of up to $ 500 billion over the past two decades ii) Eliciting private sector contribution to HIV funding: The private sector's financial contribution to HIV services was leveraged through innovative engagement and collaborative interventions iii) Private sector-led alternative HIV financing mechanisms: The introduction of 'VIP' HIV clinics, special 'HIV insurance' schemes and the rise of private philanthropic aid were important alternatives to the traditional sources of funding iv) Commodity social marketing: Commodity social marketing campaigns led to an increase in condom use among low-income earners v) The use of vouchers: Issuing of HIV-test vouchers to the poor was an important demand-side financing approach vi) Earmark HIV taxes: Several countries in Africa have introduced 'special HIV' taxes to boost domestic HIV funding. Conclusions The lessons learned from financing HIV programs suggest that a hybrid of funding strategies are advisable in the quest to achieve UHC in EAC partner states. The contribution of the private sector is indispensable and can be enhanced through targeted interventions towards UHC goals.
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Affiliation(s)
- Henry Zakumumpa
- 1Makerere University, School of Public Health, Kampala, Uganda
| | - Sara Bennett
- 2Johns Hopkins University, Bloomberg School of Public Health, Baltimore, USA
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Abstract
Any effort to improve health system performance must address the challenges of policy implementation. This article examines one aspect of implementation-the politics of policy implementation for the health sector, particularly the management of stakeholders in order to help change teams improve the chances of achieving policy objectives. Based on a literature scan of political analyses and descriptions of health policy implementation in low- and middle-income countries, we propose six major categories of stakeholder groups that are likely to influence implementation: interest group politics, bureaucratic politics, budget politics, leadership politics, beneficiary politics, and external actor politics. The categories of stakeholders can be overlapping. We examine the politics of these different stakeholder categories, and then present selected examples of published case studies that show the types of implementation challenges that arise for each category and how implementers can use political strategies to manage specific stakeholder groups and related political processes. Understanding the political dimensions of implementation can help those responsible for implementation drive policy into practice more effectively. Understanding and addressing conflict, resistance and cooperation among stakeholders are key to managing the implementation process. Systematic and continuous political analysis can help decision makers and change teams improve the chances for successful implementation.
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Affiliation(s)
- Paola Abril Campos
- Doctor of Public Health Candidate, Harvard T.H. Chan School of Public Health , Boston , MA , USA
| | - Michael R Reich
- Taro Takemi Research Professor of International Health Policy, Harvard T.H. Chan School of Public Health , Boston , MA , USA
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Haq Z, Shaikh BT, Tran N, Hafeez A, Ghaffar A. System within systems: challenges and opportunities for the Expanded Programme on Immunisation in Pakistan. Health Res Policy Syst 2019; 17:51. [PMID: 31101060 PMCID: PMC6525435 DOI: 10.1186/s12961-019-0452-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 04/07/2019] [Indexed: 11/24/2022] Open
Abstract
Background Pakistan has one of the highest infant and child mortality rates in the world, half of these occurring due to vaccine-preventable diseases. The country started its Expanded Programme on immunisation (EPI) in 1978. However, the programme’s performance is often questioned, as the Immunisation rates have been chronically low and on-time vaccination unsatisfactory. We explored the programme’s insights about its structural and implementation arrangements within the larger governance system, and the ensuing challenges as well as opportunities. Methods We carried out a qualitative case study comprised of semi-structured, in-depth interviews with 34 purposively selected key informants from various tiers of immunisation policy and programme implementation. The interviews revolved around WHO’s six building blocks of a health system, their interactions with EPI counterparts, and with the outer ecological factors. Interviews were transcribed and content analysed for emergent themes. Results The EPI faces several challenges in delivering routine immunisation (RI) to children, including lack of clarity on whether to provide vaccination through fixed centres or mobile teams, scarcity of human resource at various levels, lack of accurate population data, on-ground logistic issues, lack of a separate budget line for EPI, global pressure for polio, less priority to prevention by the policy, security risks for community-based activities, and community misconceptions about vaccines. Conclusions The fulcrum for most of the challenges lies where EPI service delivery interacts with components of the broader health system. The activities for polio eradication have had implications for RI. Socio-political issues from the national and global environment also impact this system. The interplay of these factors, while posing challenges to effective implementation of RI, also brings opportunities for improvement. Collective effort from local, national and global stakeholders is required for improving the immunisation status of Pakistani children, global health security and the sustainable development goals. Electronic supplementary material The online version of this article (10.1186/s12961-019-0452-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zaeem Haq
- Health Services Academy, Chak Shahzad, Park Road, Islamabad, 44000, Pakistan.
| | | | - Nhan Tran
- Alliance for Health Policy & Systems Research, Geneva, Switzerland
| | - Assad Hafeez
- Health Services Academy, Chak Shahzad, Park Road, Islamabad, 44000, Pakistan
| | - Abdul Ghaffar
- Alliance for Health Policy & Systems Research, Geneva, Switzerland
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Zakumumpa H, Kwiringira J, Rujumba J, Ssengooba F. Assessing the level of institutionalization of donor-funded anti-retroviral therapy (ART) programs in health facilities in Uganda: implications for program sustainability. Glob Health Action 2019; 11:1523302. [PMID: 30295159 PMCID: PMC6179085 DOI: 10.1080/16549716.2018.1523302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: In the context of declining international assistance for ART scale-up in Sub-Saharan Africa, the institutionalization of ART programs through integrating them in the organizational routines of health facilities is gaining importance as a program sustainability strategy. Objective: The aims of this study were; (i) to compare the level of institutionalization of ART programs in health facilities in Uganda and (ii) to explore reasons for variations in the degree of program institutionalization. Methods: In Phase One, we utilized Level of Institutionalization Scales developed by Goodman (1993) to measure the degree of institutionalization of ART interventions in 195 health facilities across Uganda. The 45-item questionnaire measured institutionalization based on four sub-systems (production, maintenance, supportive, managerial) theorized to make up an organization assessed against two levels of institutionalization; routines (lowest) niche saturation (highest). In Phase Two, four health facilities were purposively selected (2 with the highest and 2 with the lowest institutionalization scores) for a multiple case-study involving semi-structured interviews with ART clinic managers(n = 32), on-site observations and document review. Results: The two highest scoring health facilities had a longer HIV intervention implementation history of between 8 and 11 years. The highest scoring cases associated intervention institutionalization with sustained workforce trainings in ART management, the retention of ART-trained personnel and generating in-house ART manuals. The turnover of ART-proficient staff was identified as a barrier to intervention institutionalization in the lowest-ranked cases. Significant differences in organizational contexts were identified. The two highest-ranked health facilities were well-established, higher-tier hospitals while the lowest scoring health facilities were lower-level health facilities. Conclusions: The level of institutionalization of ART interventions appeared to be differentiated by level of care in the Ugandan health system. Interventions aimed at strengthening program institutionalization in lower-level health centers at the level of human resources for health could enhance ART scale-up sustainability.
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Affiliation(s)
- Henry Zakumumpa
- a School of Public Health , Makerere University , Kampala , Uganda
| | | | - Joseph Rujumba
- c School of Medicine , Makerere University , Kampala , Uganda
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Eboreime EA, Nxumalo N, Ramaswamy R, Ibisomi L, Ihebuzor N, Eyles J. Effectiveness of the Diagnose-Intervene- Verify-Adjust (DIVA) model for integrated primary healthcare planning and performance improvement: an embedded mixed methods evaluation in Kaduna state, Nigeria. BMJ Open 2019; 9:e026016. [PMID: 30928948 PMCID: PMC6477390 DOI: 10.1136/bmjopen-2018-026016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES This study evaluates the real-world effectiveness of Diagnose-Intervene-Verify-Adjust (DIVA), an innovative quality improvement mode, in improving primary healthcare (PHC) bottlenecks impeding health system performance in Kaduna, a northern Nigerian state. DESIGN An embedded mixed method study design involving participant observation. SETTING PHCs in 23 local government areas of Kaduna state, Nigeria. PARTICIPANTS 138 PHC managers across the state (PHC directors and programme managers in the 23 local governments). INTERVENTION DIVA is a four-step improvement model in which 'Diagnose' identifies constraints to effective coverage, 'Intervene' develops/implements action plans addressing constraints, while 'Verify/Adjust' monitor performance and revise plans. PRIMARY AND SECONDARY OUTCOME MEASURES The model, as adapted in Nigeria, is designed to evaluate and improve the availability of health commodities, human resources, geographical accessibility, acceptability, continuous utilisation and quality of four PHC interventions (immunisation, integrated management of childhood illnesses, antenatal care and skilled birth attendance). RESULTS 183 bottlenecks were identified by local government teams across all interventions in 2013. 41% of bottlenecks concern human resources. Geographical access and availability of commodities ranked least. Availability of commodities was the most improved determinant although among the least constrained, probably indicating skewed implementation of operational plans. 1562 activities were planned to address identified bottlenecks in the state, of which only 568 (36%) were completely implemented CONCLUSION: Our study demonstrates that PHC planning using the DIVA model can potentially improve health system performance. However, effective implementation is critical and may require some central government oversight.
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Affiliation(s)
- Ejemai Amaize Eboreime
- Department of Planning, Research and Statistics, National Primary Healthcare Development Agency, Abuja, Nigeria
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Nonhlanhla Nxumalo
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Rohit Ramaswamy
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Latifat Ibisomi
- Epidemiology and Biostatistics Division, School of Public Health, University of Witswaterstrand, Johannesburg, South Africa
- Research Unit, Nigerian Institute of Medical Research, Lagos, Lagos, Nigeria
| | - Nnenna Ihebuzor
- Department of PHC Systems, National Primary Healthcare Development Agency, Abuja, FCT, Nigeria
| | - John Eyles
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
- School of Geography and Earth Science, McMaster University, Hamilton, Ontario, Canada
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Integrated HIV-Care Into Primary Health Care Clinics and the Influence on Diabetes and Hypertension Care: An Interrupted Time Series Analysis in Free State, South Africa Over 4 Years. J Acquir Immune Defic Syndr 2019; 77:476-483. [PMID: 29373391 DOI: 10.1097/qai.0000000000001633] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Noncommunicable diseases (NCDs), specifically diabetes and hypertension, are rising in high HIV-burdened countries such as South Africa. How integrated HIV care into primary health care (PHC) influences NCD care is unknown. We aimed to understand whether differences existed in NCD care (pre- versus post-integration) and how changes may relate to HIV patient numbers. SETTING Public sector PHC clinics in Free State, South Africa. METHODS Using a quasiexperimental design, we analyzed monthly administrative data on 4 indicators for diabetes and hypertension (clinic and population levels) during 4 years as HIV integration was implemented in PHC. Data represented 131 PHC clinics with a catchment population of 1.5 million. We used interrupted time series analysis at ±18 and ±30 months from HIV integration in each clinic to identify changes in trends postintegration compared with those in preintegration. We used linear mixed-effect models to study relationships between HIV and NCD indicators. RESULTS Patients receiving antiretroviral therapy in the 131 PHC clinics studied increased from 1614 (April 2009) to 57, 958 (April 2013). Trends in new diabetes patients on treatment remained unchanged. However, population-level new hypertensives on treatment decreased at ±30 months from integration by 6/100, 000 (SE = 3, P < 0.02) and was associated with the number of new patients with HIV on treatment at the clinics. CONCLUSIONS Our findings suggest that during the implementation of integrated HIV care into PHC clinics, care for hypertensive patients could be compromised. Further research is needed to understand determinants of NCD care in South Africa and other high HIV-burdened settings to ensure patient-centered PHC.
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Bhatia T, Enoch J, Khan M, Mathewson S, Heymann D, Hayes R, Dar O. Setting targets for HIV/AIDS-What lessons can be learned from other disease control programmes? PLoS Med 2019; 16:e1002735. [PMID: 30716068 PMCID: PMC6361469 DOI: 10.1371/journal.pmed.1002735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In a Collection Review, Richard Hayes and colleagues discuss metrics for assessing progress in control of the HIV/AIDS epidemic in the context of prior disease control programmes.
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Affiliation(s)
| | - Jamie Enoch
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mishal Khan
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sophie Mathewson
- Chatham House Centre on Global Health Security, London, United Kingdom
| | - David Heymann
- Public Health England, London, United Kingdom
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Chatham House Centre on Global Health Security, London, United Kingdom
| | - Richard Hayes
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Osman Dar
- Public Health England, London, United Kingdom
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Chatham House Centre on Global Health Security, London, United Kingdom
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Young N, Achieng F, Desai M, Phillips-Howard P, Hill J, Aol G, Bigogo G, Laserson K, Ter Kuile F, Taegtmeyer M. Integrated point-of-care testing (POCT) for HIV, syphilis, malaria and anaemia at antenatal facilities in western Kenya: a qualitative study exploring end-users' perspectives of appropriateness, acceptability and feasibility. BMC Health Serv Res 2019; 19:74. [PMID: 30691447 PMCID: PMC6348645 DOI: 10.1186/s12913-018-3844-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 12/19/2018] [Indexed: 11/17/2022] Open
Abstract
Background HIV, syphilis, malaria and anaemia are leading preventable causes of adverse pregnancy outcomes in sub-Saharan Africa yet testing coverage for conditions other than HIV is low. Availing point-of-care tests (POCTs) at rural antenatal health facilities (dispensaries) has the potential to improve access and timely treatment. Fundamental to the adoption of and adherence to new diagnostic approaches are healthcare workers’ and pregnant women’s (end-users) buy-in. A qualitative approach was used to capture end-users’ experiences of using POCTs for HIV, syphilis, malaria and anaemia to assess the appropriateness, acceptability and feasibility of integrated testing for ANC. Methods Seven dispensaries were purposively selected to implement integrated point-of-care testing for eight months in western Kenya. Semi-structured interviews were conducted with 18 healthcare workers (14 nurses, one clinical officer, two HIV testing counsellors, and one laboratory technician) who were trained, had experience doing integrated point-of-care testing, and were still working at the facilities 8–12 months after the intervention began. The interviews explored acceptability and relevance of POCTs to ANC, challenges with testing, training and supervision, and healthcare workers’ perspectives of client experiences. Twelve focus group discussions with 118 pregnant women who had attended a first ANC visit at the study facilities during the intervention were conducted to explore their knowledge of HIV, syphilis, malaria, and anaemia, experience of ANC point-of-care testing services, treatments received, relationships with healthcare workers, and experience of talking to partners about HIV and syphilis results. Results Healthcare workers reported that they enjoyed gaining new skills, were enthusiastic about using POCTs, and found them easy to use and appropriate to their practice. Initial concerns that performing additional testing would increase their workload in an already strained environment were resolved with experience and proficiency with the testing procedures. However, despite having the diagnostic tools, general health system challenges such as high client to healthcare worker volume ratio, stock-outs and poor working conditions challenged the delivery of adequate counselling and management of the four conditions. Pregnant women appreciated POCTs, but reported poor healthcare worker attitudes, drug stock-outs, and fear of HIV disclosure to their partners as shortcomings to their ANC experience in general. Conclusion This study provides insights on the acceptability, appropriateness, and feasibility of integrating POCTs into ANC services among end-users. While the innovation was desired and perceived as beneficial, future scale-up efforts would need to address health system weaknesses if integrated testing and subsequent effective management of the four conditions are to be achieved. Electronic supplementary material The online version of this article (10.1186/s12913-018-3844-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicole Young
- Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Florence Achieng
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Meghna Desai
- Division of Parasitic Diseases and Malaria and Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Jenny Hill
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - George Aol
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Godfrey Bigogo
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Kayla Laserson
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Idindili BM, King SJ, Stolka K, Mashasi I, Bashosho P, Karungula H, Chintowa F, Mwakabole G, Ashburn K, Do B, Goco N. HIV care and treatment clinic performance following President’s Emergency Plan for AIDS Relief-funded infrastructure improvement in Tanzania. South Afr J HIV Med 2018. [DOI: 10.4102/sajhivmed.v19i1.777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Purpose: To assess how the infrastructure improvements supported by the US Centers for Disease Control and Prevention (CDC) and the United States President’s Emergency Plan for AIDS Relief (PEPFAR) contributed to facility-level quarterly and annual new patient enrolment in HIV care and treatment and antiretroviral therapy (ART) uptake and retention in care.Methods: Aggregate quarterly and annual facility-based HIV care and treatment data from the CDC-managed PEPFAR Reporting Online and Management Information System database collected between 2005 and 2012 were analysed for the 11 rural and 32 urban facilities that met the eligibility criteria. Infrastructure improvements, including both renovations and new construction, occurred on different dates for the facilities; therefore, data were adjusted such that pre- and post-infrastructure improvements were aligned and date-time was ignored. The analysis calculated the mean (95% confidence interval) number of patients per facility who were (1) newly enrolled in HIV care, (2) patients initiated on ART, (3) patients retained in care, defined as alive and on ART, and (4) reasons for attrition, defined as transferred out, lost to follow-up, deceased or stopped ART.Results: The overall mean number of adult patients newly enrolled in HIV care clinics per quarter declined from 187.7 (151.4–223.9) to 135.2 (117.4–152.9) after infrastructure improvements but was not statistically significant (p = 0.20). However, the mean number of patients who were alive and remained on ART increased from 193.2 (145.3–241.1) to 273.2 (219.0–327.3) after improvements in both rural and urban facilities, although not significantly (p = 0.59). A similar picture was observed for overall paediatric enrolment and retention in care. Health facility-specific case studies show variations in new patient enrolment and retention in care between health facilities depending on the catchment area, population HIV prevalence and coverage of ART facilities. Regarding attrition, the mean number of adult patients lost to follow-up changed from 76.6 (20.8–132.3) to 139.4 (79.6–199.1) (p = 0.65) among rural facilities, while the mean number of children lost to follow-up increased significantly from 3.4 (0.5–6.3) to 8.7 (5.0–12.3) (p = 0.02) after improvements.Conclusion: Patient retention in care improved in HIV care and treatment facilities with infrastructure improvements. However, the overall number of patients newly enrolled and initiated on ART declined and attrition increased in facilities after improvements.
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Lo CYP. Securitizing HIV/AIDS: a game changer in state-societal relations in China? Global Health 2018; 14:50. [PMID: 29769102 PMCID: PMC5956947 DOI: 10.1186/s12992-018-0364-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 04/25/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND China has experienced unprecedented economic growth since the 1980s. Despite this impressive economic development, this growth exists side by side with the human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and severe acute respiratory syndrome (SARS) crises and the persisting deficiencies in public health provision in China. Acknowledging the prevailing health problems, the Chinese government has encouraged the development of health non-governmental organizations (NGOs) to respond to the health challenges and address the gaps in public health provision of the government. HIV/AIDS-focused NGOs have been perceived as the most outstanding civil society group developed in China. Considering the low priority of health policies since the economic reform, the limitation of the "third sector" activity permitted in authoritarian China, together with the political sensitivity of the HIV/AIDS problem in the country, this article aims to explain the proliferation of HIV/AIDS-focused NGOs in China with the usage of the securitization framework in the field of international relations (IR). METHODS The research that underpins this article is based on a desk-based literature review as well as in-depth field interviews with individuals working in HIV/AIDS-focused NGOs in China. Face-to-face interviews for this research were conducted between January and May in 2011, and between December 2016 and January 2017, in China. Discourse analysis was in particular employed in the study of the security-threat framing process (securitization) of HIV/AIDS in China. RESULTS This article argues that the proliferation of HIV/AIDS-related NGOs in China is largely attributed to the normative and technical effects of HIV/AIDS securitization ushered in by the United Nations Security Council (UNSC) and supported by the Global Fund to Fight AIDS, Tuberculosis, and Malaria (hereinafter Global Fund) observed in China. Despite depicting a positive scenario, the development of HIV/AIDS-focused NGOs in China generated by the international securitization efforts is largely limited. An internal and external factor was identified to verify the argument, namely (1) the reduction of international financial commitments, as well as (2) the fragmentation of HIV/AIDS-focused NGO community in China. CONCLUSIONS This article shows that international securitization weakened with the rise of Chinese commitment on HIV/AIDS interventions. In other words, HIV/AIDS-related responses delivered by the national government are no longer checked by the global mechanism of HIV/AIDS; thus it is unclear whether these NGOs would remain of interest as partners for the government. The fragmentation of the HIV/AIDS community would further hinder the development, preventing from NGOs with the same interest forming alliances to call for changes in current political environment. Such restriction on the concerted efforts of HIV/AIDS-related NGOs in China would make achievement of the Sustainable Development Goals (SDGs) to foster stronger partnerships between the government and civil society difficult, which in turn hindering the realization of ending HIV/AIDS in the world by 2030.
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Affiliation(s)
- Catherine Yuk-Ping Lo
- Southeast Asia Research Centre, College of Liberal Arts and Social Sciences, City University of Hong Kong, 83 Tat Chee Avenue, Kowloon Tong, Hong Kong.
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Rawat A, Uebel K, Moore D, Cingl L, Yassi A. Patient Responses on Quality of Care and Satisfaction with Staff After Integrated HIV Care in South African Primary Health Care Clinics. J Assoc Nurses AIDS Care 2018; 29:698-711. [PMID: 29857926 DOI: 10.1016/j.jana.2018.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 04/30/2018] [Indexed: 10/16/2022]
Abstract
HIV care integrated into primary health care (PHC) encourages reorganized service delivery but could increase workload. In 2012-2013, we surveyed 910 patients and caregivers at two time points after integration in four clinics in Free State, South Africa. Likert surveys measured quality of care (QoC) and satisfaction with staff (SwS). QoC scores were lower for females, those older than 56 years, those visiting clinics every 3 months, and child health participants. Regression estimates showed QoC scores higher for ages 36-45 versus 18-25 years, and lower for those attending clinics for more than 10 years versus 6-12 months. Overall, SwS scores were lower for child health attendees and higher for tuberculosis attendees compared to chronic disease care attendees. Research is needed to understand determinants of disparities in QoC and SwS, especially for child health, diabetes, and hypertension attendees, to ensure high-quality care experiences for all patients attending PHC clinics with integrated HIV care.
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Gupta V, Mason-Sharma A, Lyon ZM, Orav EJ, Jha AK, Kerry VB. Has development assistance for health facilitated the rise of more peaceful societies in sub-Saharan Africa? Glob Public Health 2018. [PMID: 29532733 DOI: 10.1080/17441692.2018.1449232] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Growing evidence suggests that health aid can serve humanitarian and diplomatic ends. This study utilised the Fragile States Index (FSI) for the 47 nations of the World Health Organizations' Africa region for the years 2005-2014 and data on health and non-health development aid spending from the United States (US) for those same years. Absolute amounts of health and non-health aid flows from the US were used as predictors of state fragility. We used time-lagged, fixed-effects multivariable regression modelling with change in FSI as the outcome of interest. The highest quartile of US health aid per capita spending (≥$4.00 per capita) was associated with a large and immediate decline in level of state fragility (b = -7.57; 95% CI, -14.6 to -0.51, P = 0.04). A dose-response effect was observed in the primary analysis, with increasing levels of spending associated with greater declines in fragility. Health per-capita expenditures were correlated with improved fragility scores across all lagged intervals and spending quartiles. The association of US health aid with immediate improvements in metrics of state stability across sub-Saharan Africa is a novel finding. This effect is possibly explained by our observations that relative to non-health aid, US health expenditures were larger and more targeted.
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Affiliation(s)
- Vin Gupta
- a Harvard Global Health Institute , Harvard University , Cambridge , USA.,b Department of Pulmonary & Critical Care Medicine , Brigham & Women's Hospital , Boston , USA
| | | | - Zoe M Lyon
- a Harvard Global Health Institute , Harvard University , Cambridge , USA.,d Department of Health Policy and Management , Harvard T.H. Chan School of Public Health , Boston , USA
| | - Endel John Orav
- d Department of Health Policy and Management , Harvard T.H. Chan School of Public Health , Boston , USA
| | - Ashish K Jha
- d Department of Health Policy and Management , Harvard T.H. Chan School of Public Health , Boston , USA.,e Harvard Global Health Institute , Harvard University , Cambridge , USA
| | - Vanessa B Kerry
- f Department of Global Health and Social Medicine , Harvard Medical School , Boston , USA.,g MGH Global Health , Massachusetts General Hospital , Boston , USA.,h Division of Pulmonary and Critical Care , Massachusetts General Hospital , Boston , USA.,i Seed Global Health , Boston , USA
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Goodman ML, Serag H, Gitari S, Keiser PH, Dacso M, Raimer BG. Exploring Pathways Between HIV+ Status and Excellent Overall Health Among Kenyan Women: Family Functioning, Meaningfulness of Life, Seroconcordance, Social Support and Considering the Need for Integrated Care. J Community Health 2018; 41:989-97. [PMID: 27000039 DOI: 10.1007/s10900-016-0181-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
As people living with HIV/AIDS (PLWHA) live longer, and HIV incidence declines, health systems are transitioning from vertical-only care delivery to horizontal integration with social and other services. This is essential to responding to the chronic nature of the disease, and health systems must respond to full-breadth of socio-economic conditions facing PLWHA. We use excellent self-rated health as a referent, and assess the role of non-biomedical conditions in mediating HIV+ status and excellent overall health among a large community sample of Kenyan women. After controlling for age and wealth, we found significant mediation by social support, partner HIV status, meaningfulness of life, family functioning, food sufficiency, and monthly income. If the goal of health systems is to help all people attain the highest level of health, integrating vertical HIV services with socio-economic support and empowerment may be required. Further investigation of the relative contribution of social support, family functioning, food and financial sufficiency should be conducted longitudinally, ideally in collaboration with HIV clinical services.
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Affiliation(s)
- Michael L Goodman
- University of Texas Medical Branch, Galveston, TX, 77550, USA. .,Sodzo International, Houston, TX, 77002, USA. .,, 301 University Blvd, Marvin Graves 4.314c, Galveston, TX, 77555, USA.
| | - Hani Serag
- University of Texas Medical Branch, Galveston, TX, 77550, USA
| | | | - Philip H Keiser
- University of Texas Medical Branch, Galveston, TX, 77550, USA
| | - Matthew Dacso
- University of Texas Medical Branch, Galveston, TX, 77550, USA
| | - Ben G Raimer
- University of Texas Medical Branch, Galveston, TX, 77550, USA
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Minior T, Douglas M, Edgil D, Srivastava M, Crowley J, Firth J, Lapidos-Salaiz I, Williams J, Lee L. The Critical Role of Supply Chains in Preventing Human Immunodeficiency Virus Drug Resistance in Low- and Middle-Income Settings. J Infect Dis 2017; 216:S812-S815. [PMID: 29029317 DOI: 10.1093/infdis/jix403] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The functioning of the supply chain may be a driving factor behind the development of human immunodeficiency virus (HIV) drug resistance (HIVDR) in many low- and middle-income countries (LMICs). Additionally, the effectiveness of supply chains will likely impact the scale-up of both viral-load monitoring and HIVDR testing. This article describes the complexities of global supply chains relevant for LMICs and presents early data on stock-outs and drug substitutions in several countries supported by the US President's Emergency Plan for AIDS Relief. Supply chain systems will need to be strengthened to minimize interruptions as new antiretroviral therapy regimens are introduced and to facilitate adoption of new laboratory technologies.
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Affiliation(s)
- Thomas Minior
- Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development
| | - Meaghan Douglas
- Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development
| | - Dianna Edgil
- Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development
| | - Meena Srivastava
- Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development
| | - John Crowley
- Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development
| | - Jacqueline Firth
- Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development
| | - Ilana Lapidos-Salaiz
- Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development
| | - Jason Williams
- Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development
| | - Lana Lee
- Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development
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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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The ART Advantage: Health Care Utilization for Diabetes and Hypertension in Rural South Africa. J Acquir Immune Defic Syndr 2017; 75:561-567. [PMID: 28696346 DOI: 10.1097/qai.0000000000001445] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The prevalence of diabetes and hypertension has increased in HIV-positive populations, but there is limited understanding of the role that antiretroviral therapy (ART) programs play in the delivery of services for these conditions. The aim of this study is to assess the relationship between ART use and utilization of health care services for diabetes and hypertension. METHODS Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa is a cohort of 5059 adults. The baseline study collects biomarker-based data on HIV, ART, diabetes, and hypertension and self-reported data on health care utilization. We calculated differences in care utilization for diabetes and hypertension by HIV and ART status and used multivariable logistic regressions to estimate the relationship between ART use and utilization of services for these conditions, controlling for age, sex, body mass index, education, and household wealth quintile. RESULTS Mean age, body mass index, hypertension, and diabetes prevalence were lower in the HIV-positive population (all P < 0.001). Multivariable logistic regression showed that ART use was significantly associated with greater odds of blood pressure measurement [adjusted odds ratio (aOR) 1.27, 95% confidence interval (CI): 1.04 to 1.55] and blood sugar measurement (aOR 1.26, 95% CI: 1.05 to 1.51), counseling regarding exercise (aOR 1.57, 95% CI: 1.11 to 2.22), awareness of hypertension diagnosis (aOR 1.52, 95% CI: 1.12 to 2.05), and treatment for hypertension (aOR 1.63, 95% CI: 1.21 to 2.19). CONCLUSIONS HIV-positive patients who use ART are more likely to have received health care services for diabetes and hypertension. This apparent ART advantage suggests that ART programs may be a vehicle for strengthening health systems for chronic care.
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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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Wu S, Roychowdhury I, Khan M. Evaluations of training programs to improve human resource capacity for HIV, malaria, and TB control: a systematic scoping review of methods applied and outcomes assessed. Trop Med Health 2017; 45:16. [PMID: 28680324 PMCID: PMC5493875 DOI: 10.1186/s41182-017-0056-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/16/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Owing to the global health workforce crisis, more funding has been invested in strengthening human resources for health, particularly for HIV, tuberculosis, and malaria control; however, little is known about how these investments in training are evaluated. This paper examines how frequently HIV, malaria, and TB healthcare provider training programs have been scientifically evaluated, synthesizes information on the methods and outcome indicators used, and identifies evidence gaps for future evaluations to address. METHODS We conducted a systematic scoping review of publications evaluating postgraduate training programs, including in-service training programs, for HIV, tuberculosis, and malaria healthcare providers between 2000 and 2016. Using broad inclusion criteria, we searched three electronic databases and additional gray literature sources. After independent screening by two authors, data about the year, location, methodology, and outcomes assessed was extracted from eligible training program evaluation studies. Training outcomes evaluated were categorized into four levels (reaction, learning, behavior, and results) based on the Kirkpatrick model. FINDINGS Of 1473 unique publications identified, 87 were eligible for inclusion in the analysis. The number of published articles increased after 2006, with most (n = 57, 66%) conducted in African countries. The majority of training evaluations (n = 44, 51%) were based on HIV with fewer studies focused on malaria (n = 28, 32%) and TB (n = 23, 26%) related training. We found that quantitative survey of trainees was the most commonly used evaluation method (n = 29, 33%) and the most commonly assessed outcomes were knowledge acquisition (learning) of trainees (n = 44, 51%) and organizational impacts of the training programs (38, 44%). Behavior change and trainees' reaction to the training were evaluated less frequently and using less robust methods; costs of training were also rarely assessed. CONCLUSIONS Our study found that a limited number of robust evaluations had been conducted since 2000, even though the number of training programs has increased over this period to address the human resource shortage for HIV, malaria, and TB control. Specifically, we identified a lack evaluation studies on TB- and malaria-related healthcare provider training and very few studies assessing behavior change of trainees or costs of training. Developing frameworks and standardized evaluation methods may facilitate strengthening of the evidence base to inform policies on and investments in training programs.
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Affiliation(s)
- Shishi Wu
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore, 117549 Singapore
| | - Imara Roychowdhury
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore, 117549 Singapore
| | - Mishal Khan
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore, 117549 Singapore.,Communicable Diseases Policy Research Group, London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT United Kingdom
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Ning C, Smith KM, McCann CD, Hu F, Lan Y, Zhang F, Liang H, Zhao J, Tucker JD, Cai W. Outcome of Sentinel Hospital-based and CDC-based ART Service Delivery: A Prospective Open Cohort of People Living with HIV in China. Sci Rep 2017; 7:42637. [PMID: 28195204 PMCID: PMC5307364 DOI: 10.1038/srep42637] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 01/13/2017] [Indexed: 11/09/2022] Open
Abstract
The primary objective of this study was to obtain insights into the outcomes of people living with HIV who accessed services through HIV/AIDS sentinel hospital-based and ART service delivery in China. Post-hoc analyses of an open cohort from an observational database of 22 qualified HIV/AIDS sentinel hospital-based and two CDC-based drug delivery facilities (DDFs) in Guangdong Province was completed. Linkage to care, mortality and survival rates were calculated according to WHO criteria. 12,966 individuals received ART from HIV/AIDS sentinel hospitals and 1,919 from DDFs, with linkage to care rates of 80.7% and 79.9%, respectively (P > 0.05). Retention rates were 94.1% and 84.0% in sentinel hospitals and DDFs, respectively (P < 0.01). Excess mortality was 1.4 deaths/100 person-years (95% CI: 1.1, 1.8) in DDFs compared to 0.4 deaths/100 person-years (95% CI: 0.3, 0.5) in hospitals (P < 0.01). A Cox-regression analysis revealed that mortality was much higher in patients receiving ART from the DDFs than sentinel hospitals, with an adjusted HR of 3.3 (95% CI: 2.3, 4.6). A crude HR of treatment termination in DDFs was 7.5 fold higher (95% CI: 6.3, 9.0) compared to sentinel hospitals. HIV/AIDS sentinel hospital had better retention, and substantially lower mortality compared to DDFs.
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Affiliation(s)
- Chuanyi Ning
- Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China.,The University of North Carolina Project-China, Guangzhou, Guangdong, China.,Department of Infection Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Medical Scientific Research Center &Guangxi Key Laboratory of AIDS Prevention and Treatment, Guangxi Medical University, Guangxi, China
| | - Kumi M Smith
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Chase D McCann
- Department of Microbiology &Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Fengyu Hu
- Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yun Lan
- Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Fuchun Zhang
- Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Hao Liang
- Medical Scientific Research Center &Guangxi Key Laboratory of AIDS Prevention and Treatment, Guangxi Medical University, Guangxi, China
| | - Jinmin Zhao
- Medical Scientific Research Center &Guangxi Key Laboratory of AIDS Prevention and Treatment, Guangxi Medical University, Guangxi, China
| | - Joseph D Tucker
- The University of North Carolina Project-China, Guangzhou, Guangdong, China.,Department of Infection Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Weiping Cai
- Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, Guangdong, China.,The University of North Carolina Project-China, Guangzhou, Guangdong, China
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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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Ooms G, Beiersmann C, Flores W, Hanefeld J, Müller O, Mulumba M, Ottersen T, Sarker M, Jahn A. Synergies and tensions between universal health coverage and global health security: why we need a second 'Maximizing Positive Synergies' initiative. BMJ Glob Health 2017; 2:e000217. [PMID: 28589005 PMCID: PMC5321394 DOI: 10.1136/bmjgh-2016-000217] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 01/03/2017] [Accepted: 01/04/2017] [Indexed: 11/25/2022] Open
Affiliation(s)
- Gorik Ooms
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Institute of Public Health, Heidelberg University Hospital, Heidelberg, Germany
| | - Claudia Beiersmann
- Institute of Public Health, Heidelberg University Hospital, Heidelberg, Germany
| | - Walter Flores
- Center for the Study of Equity and Governance in Health Systems, Guatemala, Guatemala
| | - Johanna Hanefeld
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Olaf Müller
- Institute of Public Health, Heidelberg University Hospital, Heidelberg, Germany
| | - Moses Mulumba
- Center for Health, Human Rights and Development, Kampala, Uganda
| | - Trygve Ottersen
- Oslo Group on Global Health Policy, Department of Community Medicine and Global Health and the Centre for Global Health, University of Oslo, Oslo, Norway
| | - Malabika Sarker
- James P. Grant School of Public Health at BRAC University, Dhaka, Bangladesh
| | - Albrecht Jahn
- Institute of Public Health, Heidelberg University Hospital, Heidelberg, Germany
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Jobson GA, Grobbelaar CJ, Mabitsi M, Railton J, Peters RPH, McIntyre JA, Struthers HE. Delivering HIV services in partnership: factors affecting collaborative working in a South African HIV programme. Global Health 2017; 13:3. [PMID: 28086914 PMCID: PMC5237257 DOI: 10.1186/s12992-016-0228-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 12/20/2016] [Indexed: 11/25/2022] Open
Abstract
Background The involvement of Global Health Initiatives (GHIs) in delivering health services in low and middle income countries (LMICs) depends on effective collaborative working at scales from the local to the international, and a single GHI is effectively constructed of multiple collaborations. Research is needed focusing on how collaboration functions in GHIs at the level of health service management. Here, collaboration between local implementing agencies and departments of health involves distinct power dynamics and tensions. Using qualitative data from an evaluation of a health partnership in South Africa, this article examines how organisational power dynamics affected the operation of the partnership across five dimensions of collaboration: governance, administration, organisational autonomy, mutuality, and norms of trust and reciprocity. Results Managing the tension between the power to provide resources held by the implementing agency and the local Departments’ of Health power to access the populations in need of these resources proved critical to ensuring that the collaboration achieved its aims and shaped the way that each domain of collaboration functioned in the partnership. Conclusions These findings suggest that it is important for public health practitioners to critically examine the ways in which collaboration functions across the scales in which they work and to pay particular attention to how local power dynamics between partner organisations affect programme implementation.
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Affiliation(s)
- Geoffrey A Jobson
- Anova Health Institute, 12 Sherborne Rd, Park Town, Johannesburg, 2190, South Africa.
| | - Cornelis J Grobbelaar
- Anova Health Institute, 12 Sherborne Rd, Park Town, Johannesburg, 2190, South Africa
| | - Moyahabo Mabitsi
- Anova Health Institute, 12 Sherborne Rd, Park Town, Johannesburg, 2190, South Africa
| | - Jean Railton
- Anova Health Institute, 12 Sherborne Rd, Park Town, Johannesburg, 2190, South Africa
| | - Remco P H Peters
- Anova Health Institute, 12 Sherborne Rd, Park Town, Johannesburg, 2190, South Africa
| | - James A McIntyre
- Anova Health Institute, 12 Sherborne Rd, Park Town, Johannesburg, 2190, South Africa.,School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen E Struthers
- Anova Health Institute, 12 Sherborne Rd, Park Town, Johannesburg, 2190, South Africa.,Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Odekunle FF, Odekunle RO. The impact of the US president's emergency plan for AIDS relief (PEPFAR) HIV and AIDS program on the Nigerian health system. Pan Afr Med J 2016; 25:143. [PMID: 28292105 PMCID: PMC5326074 DOI: 10.11604/pamj.2016.25.143.9987] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 10/31/2016] [Indexed: 11/30/2022] Open
Abstract
The PEPFAR HIV/AIDS program has had noticeable impacts on the Nigerian health system. The impacts are presented using the World Health Organization (WHO) health system six building blocks. These include service delivery, health workforce, health information, medical products, vaccines and technologies, financing and governance. PEPFAR HIV/AIDS program has improved the delivery of prevention and care services for people living with HIV/AIDS (PLWHA). The most important measure of PEPFAR’s success is the availability of free ART in Nigeria for PLWHA who need this. The PEPFAR program has brought about increased political awareness of and raised the priority given to public health by governments and civil society through its scaling up response to HIV/AIDS. The scaled-up program has direct benefits on the health workforce by preserving HIV-infected health personnel’s lives so that they can live longer enjoy a better quality of life and return to their jobs; all of which invariably enhances the country’s health workforce. Moreover, the training and retraining in PEPFAR HIV/AIDS program have boosted both the morale and the skills of the health workforce. Considerable resources have been brought into Nigeria for scaled-up HIV/AIDS treatment by PEPFAR. However, this has contributed to the development of donor dependency syndrome by Nigerian government. There is a non-alignment between PEPFAR HIV/AIDS program and the recipient country’s health system. Attention to maternal mortality and other reproductive health services has suffered as non-governmental organizations (NGOs) pursue AIDS money and local governments receive signals from the political center to prioritize HIV/AIDS over other problems that are just as serious. A functional health system is important in prevention of the HIV epidemic. Hence efforts should be made to strengthen health systems. The PEPFAR HIV/AIDS program should be harmonized with the country’s health system for maximum impact.
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Bärnighausen T, Bloom DE, Humair S. Human Resources for Treating HIV/AIDS: Are the Preventive Effects of Antiretroviral Treatment a Game Changer? PLoS One 2016; 11:e0163960. [PMID: 27716813 PMCID: PMC5055321 DOI: 10.1371/journal.pone.0163960] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 09/16/2016] [Indexed: 11/19/2022] Open
Abstract
Shortages of human resources for treating HIV/AIDS (HRHA) are a fundamental barrier to reaching universal antiretroviral treatment (ART) coverage in developing countries. Previous studies suggest that recruiting HRHA to attain universal ART coverage poses an insurmountable challenge as ART significantly increases survival among HIV-infected individuals. While new evidence about ART's prevention benefits suggests fewer infections may mitigate the challenge, new policies such as treatment-as-prevention (TasP) will exacerbate it. We develop a mathematical model to analytically study the net effects of these countervailing factors. Using South Africa as a case study, we find that contrary to previous results, universal ART coverage is achievable even with current HRHA numbers. However, larger health gains are possible through a surge-capacity policy that aggressively recruits HRHA to reach universal ART coverage quickly. Without such a policy, TasP roll-out can increase health losses by crowding out sicker patients from treatment, unless a surge capacity exclusively for TasP is also created.
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Affiliation(s)
- Till Bärnighausen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Africa Health Research Institute (AHRI), Mtubatuba, KwaZulu Natal, South Africa
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - David E. Bloom
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Salal Humair
- Amazon.com, Inc., Seattle, Washington, United States of America
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Luboga SA, Stover B, Lim TW, Makumbi F, Kiwanuka N, Lubega F, Ndizihiwe A, Mukooyo E, Hurley EK, Borse N, Wood A, Bernhardt J, Lohman N, Sheppard L, Barnhart S, Hagopian A. Did PEPFAR investments result in health system strengthening? A retrospective longitudinal study measuring non-HIV health service utilization at the district level. Health Policy Plan 2016; 31:897-909. [PMID: 27017824 PMCID: PMC4977428 DOI: 10.1093/heapol/czw009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2016] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES : PEPFAR's initial rapid scale-up approach was largely a vertical effort focused fairly exclusively on AIDS. The purpose of our research was to identify spill-over health system effects, if any, of investments intended to stem the HIV epidemic over a 6-year period with evidence from Uganda. The test of whether there were health system expansions (aside from direct HIV programming) was evidence of increases in utilization of non-HIV services-such as outpatient visits, in-facility births or immunizations-that could be associated with varying levels of PEPFAR investments at the district level. METHODS : Uganda's Health Management Information System article-based records were available from mid-2005 onwards. We visited all 112 District Health offices to collect routine monthly reports (which contain data aggregated from monthly facility reports) and annual reports (which contain data aggregated from annual facility reports). Counts of individuals on anti-retroviral therapy (ART) at year-end served as our primary predictor variable. We grouped district-months into tertiles of high, medium or low PEPFAR investment based on their total reported number of patients on ART at the end of the year. We generated incidence-rate ratios, interpreted as the relative rate of the outcome measure in relation to the lowest investment PEPFAR tertile, holding constant control variables in the model. RESULTS : We found PEPFAR investment overall was associated with small declines in service volumes in several key areas of non-HIV care (outpatient care for young children, TB tests and in-facility deliveries), after adjusting for sanitation, elementary education and HIV prevalence. For example, districts with medium and high ART investment had 11% fewer outpatient visits for children aged 4 and younger compared with low investment districts, incidence rate ratio (IRR) of 0.89 for high investment compared with low (95% CI, 0.85-0.94) and IRR of 0.93 for medium compared with low (0.90-0.96). Similarly, 22% fewer TB sputum tests were performed in high investment districts compared with low investment, [IRR 0.78 (0.72-0.85)] and 13% fewer in medium compared with low, [IRR 0.88 (0.83-0.94)]. Districts with medium and high ART investment had 5% fewer in-facility deliveries compared with low investment districts [IRR 0.95 for high compared with low, (91-1.00) and 0.96 for medium compared with low (0.93-0.99)]. Although not statistically significant, the rate of maternal deaths in high investment district-months was 13% lower than observed in low investment districts. CONCLUSIONS : This study sought to understand whether PEPFAR, as a vertical programme, may have had a spill-over effect on the health system generally, as measured by utilization. Our conclusion is that it did not, at least not in Uganda.
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Affiliation(s)
- Samuel Abimerech Luboga
- Faculty of Health Sciences, Makerere University, PO Box 7062, Kampala University Road, Kampala, Uganda
| | - Bert Stover
- Department of Health Services, University of Washington, PO Box 357660, Seattle, WA 98195, USA
| | - Travis W Lim
- Division of Global HIV and Tuberculosis, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Frederick Makumbi
- Faculty of Health Sciences, Makerere University, PO Box 7062, Kampala University Road, Kampala, Uganda
| | - Noah Kiwanuka
- Faculty of Health Sciences, Makerere University, PO Box 7062, Kampala University Road, Kampala, Uganda
| | - Flavia Lubega
- Faculty of Health Sciences, Makerere University, PO Box 7062, Kampala University Road, Kampala, Uganda
| | - Assay Ndizihiwe
- Division of Global HIV and Tuberculosis, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Eddie Mukooyo
- Resource Center for the Uganda Ministry of Health, Uganda Ministry of Health, PO Box 7272 Kampala Uganda Plot 6 Lourdel Road, Nakasero
| | - Erin K Hurley
- Division of Global HIV and Tuberculosis, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Nagesh Borse
- Division of Global HIV and Tuberculosis, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Angela Wood
- Department of Global Health, University of Washington, PO Box 357965, Seattle, WA 98195, USA and
| | - James Bernhardt
- Department of Global Health, University of Washington, PO Box 357965, Seattle, WA 98195, USA and
| | - Nathaniel Lohman
- Department of Global Health, University of Washington, PO Box 357965, Seattle, WA 98195, USA and
| | - Lianne Sheppard
- Department of Biostatistics, University of Washington, PO Box 357232, Seattle, WA 98195, USA
| | - Scott Barnhart
- Department of Global Health, University of Washington, PO Box 357965, Seattle, WA 98195, USA and
| | - Amy Hagopian
- Department of Health Services, University of Washington, PO Box 357660, Seattle, WA 98195, USA Department of Global Health, University of Washington, PO Box 357965, Seattle, WA 98195, USA and
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42
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Affiliation(s)
- Nana K Poku
- University of KwaZulu-Natal, Private Bag X54001, Durban 4000, South Africa.
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Shrivastava R, Gadde R, Nkengasong JN. Importance of Public-Private Partnerships: Strengthening Laboratory Medicine Systems and Clinical Practice in Africa. J Infect Dis 2016; 213 Suppl 2:S35-40. [PMID: 27025696 DOI: 10.1093/infdis/jiv574] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
After the launch of the US President's Emergency Plan for AIDS Relief in 2003, it became evident that inadequate laboratory systems and services would severely limit the scale-up of human immunodeficiency virus infection prevention, care, and treatment programs. Thus, the Office of the US Global AIDS Coordinator, Centers for Disease Control and Prevention, and Becton, Dickinson and Company developed a public-private partnership (PPP). Between October 2007 and July 2012, the PPP combined the competencies of the public and private sectors to boost sustainable laboratory systems and develop workforce skills in 4 African countries. Key accomplishments of the initiative include measurable and scalable outcomes to strengthen national capacities to build technical skills, develop sample referral networks, map disease prevalence, support evidence-based health programming, and drive continuous quality improvement in laboratories. This report details lessons learned from our experience and a series of recommendations on how to achieve successful PPPs.
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Affiliation(s)
- Ritu Shrivastava
- International Laboratory Branch, Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Renuka Gadde
- Becton, Dickinson, and Company, Franklin Lakes, New Jersey
| | - John N Nkengasong
- International Laboratory Branch, Division of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
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Dominique JK, Ortiz-Osorno AA, Fitzgibbon J, Gnanashanmugam D, Gilpin C, Tucker T, Peel S, Peter T, Kim P, Smith S. Implementation of HIV and Tuberculosis Diagnostics: The Importance of Context. Clin Infect Dis 2016; 61Suppl 3:S119-25. [PMID: 26409272 DOI: 10.1093/cid/civ552] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Novel diagnostics have been widely applied across human immunodeficiency virus (HIV) and tuberculosis prevention and treatment programs. To achieve the greatest impact, HIV and tuberculosis diagnostic programs must carefully plan and implement within the context of a specific healthcare system and the laboratory capacity. METHODS A workshop was convened in Cape Town in September 2014. Participants included experts from laboratory and clinical practices, officials from ministries of health, and representatives from industry. RESULTS The article summarizes best practices, challenges, and lessons learned from implementation experiences across sub-Saharan Africa for (1) building laboratory programs within the context of a healthcare system; (2) utilizing experience of clinicians and healthcare partners in planning and implementing the right diagnostic; and (3) evaluating the effects of new diagnostics on the healthcare system and on patient health outcomes. CONCLUSIONS The successful implementation of HIV and tuberculosis diagnostics in resource-limited settings relies on careful consideration of each specific context.
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Affiliation(s)
- Joyelle K Dominique
- Office of Global Research, Office of Science Management and Operations, Office of the Director
| | - Alberto A Ortiz-Osorno
- Clinical Research Implementation Subject Matter Expert, Henry M. Jackson Foundation, Division of AIDS Therapeutic Research Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, US Department of Health and Human Services, Rockville, Maryland
| | - Joseph Fitzgibbon
- Therapeutic Research Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, US Department of Health and Human Services, Rockville, Maryland
| | | | | | - Timothy Tucker
- Strategic Evaluation, Advisory and Development Consulting, Cape Town, South Africa
| | - Sheila Peel
- Diagnostics and Laboratory Monitoring, US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Trevor Peter
- Diagnostics, Clinton Health Access Initiative, Gaborone, Botswana
| | - Peter Kim
- Adolescent and Pediatric Research Branch, Prevention Sciences Program, Division of AIDS
| | - Steven Smith
- Office of Global Affairs, Office of the Secretary, US Department of Health and Human Services, Pretoria, South Africa
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Hontelez JAC, Tanser FC, Naidu KK, Pillay D, Bärnighausen T. The Effect of Antiretroviral Treatment on Health Care Utilization in Rural South Africa: A Population-Based Cohort Study. PLoS One 2016; 11:e0158015. [PMID: 27384178 PMCID: PMC4934780 DOI: 10.1371/journal.pone.0158015] [Citation(s) in RCA: 8] [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: 01/18/2016] [Accepted: 06/08/2016] [Indexed: 12/30/2022] Open
Abstract
Background The effect of the rapid scale-up of vertical antiretroviral treatment (ART) programs for HIV in sub-Saharan Africa on the overall health system is under intense debate. Some have argued that these programs have reduced access for people suffering from diseases unrelated to HIV because ART programs have drained human and physical resources from other parts of the health system; others have claimed that the investments through ART programs have strengthened the general health system and the population health impacts of ART have freed up health care capacity for the treatment of diseases that are not related to HIV. To establish the population-level impact of ART programs on health care utilization in the public-sector health system, we compared trends in health care utilization among HIV-infected people receiving and not receiving ART with HIV-uninfected people during a period of rapid ART scale-up. Methods and Findings We used data from the Wellcome Trust Africa Centre for Population Health, which annually elicited information on health care utilization from all surveillance participants over the period 2009–2012 (N = 32,319). We determined trends in hospitalization, and public-sector and private-sector primary health care (PHC) clinic visits for HIV-infected and -uninfected people over a time period of rapid ART scale-up (2009–2012) in this community. We regressed health care utilization on HIV status and ART status in different calendar years, controlling for sex, age, and area of residence. The proportion of people who reported to have visited a public-sector primary health care (PHC) clinic in the last 6 months increased significantly over the period 2009–2012, for both HIV-infected people (from 59% to 67%; p<0.001), and HIV-uninfected people (from 41% to 47%; p<0.001). In contrast, the proportion of HIV-infected people visiting a private-sector PHC clinic declined from 22% to 12% (p<0.001) and hospitalization rates declined from 128 to 82 per 1000 PY (p<0.001). For HIV-uninfected people, the proportion visiting a private-sector PHC clinic declined from 16% to 9%, and hospitalization rates declined from 78 to 44 per 1000 PY (p<0.001). After controlling for potential confounding factors, all trends remained of similar magnitude and significance. Conclusions Our results indicate that the ART scale-up in this high HIV prevalence community has shifted health care utilization from hospitals and private-sector primary care to public-sector primary care. Remarkably, this shift is observed for both HIV-infected and -uninfected populations, supporting and extending hypotheses of ‘therapeutic citizenship’ whereby HIV-infected patients receiving ART facilitate primary care access for family and community members. One explanation of our findings is that ART has improved the capacity or quality of primary care in this community and, as a consequence, increasingly met overall health care needs at the primary care level rather than at the secondary level. Future research needs to confirm this causal interpretation of our findings using qualitative work to understand causal mechanisms or quasi-experimental quantitative studies to increase the strength of causal inference.
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Affiliation(s)
- Jan A. C. Hontelez
- Wellcome Trust Africa Centre for Population Health, University of KwaZulu-Natal, Mtubatuba, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, United States of America
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
- * E-mail:
| | - Frank C. Tanser
- Wellcome Trust Africa Centre for Population Health, University of KwaZulu-Natal, Mtubatuba, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Kevindra K. Naidu
- Wellcome Trust Africa Centre for Population Health, University of KwaZulu-Natal, Mtubatuba, South Africa
| | - Deenan Pillay
- Wellcome Trust Africa Centre for Population Health, University of KwaZulu-Natal, Mtubatuba, South Africa
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Till Bärnighausen
- Wellcome Trust Africa Centre for Population Health, University of KwaZulu-Natal, Mtubatuba, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, United States of America
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McNairy ML, Gwynn C, Rabkin M, Antelman G, Wu Y, Alemayehu B, Lim T, Imtiaz R, Mosha F, Mwasekaga M, Othman AA, Justman J. Increased utilisation of PEPFAR-supported laboratory services by non-HIV patents in Tanzania. Afr J Lab Med 2016; 5. [PMID: 26962475 PMCID: PMC4780676 DOI: 10.4102/ajlm.v5i1.318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND It is unknown to what extent the non-HIV population utilises laboratories supported by the President's Emergency Plan for AIDS Relief (PEPFAR). OBJECTIVES We aimed to describe the number and proportion of laboratory tests performed in 2009 and 2011 for patients referred from HIV and non-HIV services (NHSs) in a convenience sample collected from 127 laboratories supported by PEPFAR in Tanzania. We then compared changes in the proportions of tests performed for patients referred from NHSs in 2009 vs 2011. METHODS Haematology, chemistry, tuberculosis and syphilis test data were collected from available laboratory registers. Referral sources, including HIV services, NHSs, or lack of a documented referral source, were recorded. A generalised linear mixed model reported the odds that a test was from a NHS. RESULTS A total of 94 132 tests from 94 laboratories in 2009 and 157 343 tests from 101 laboratories in 2011 were recorded. Half of all tests lacked a documented referral source. Tests from NHSs constituted 42% (66 084) of all tests in 2011, compared with 31% (29 181) in 2009. A test in 2011 was twice as likely to have been referred from a NHS as in 2009 (adjusted odds ratio: 2.0 [95% confidence interval: 2.0-2.1]). CONCLUSION Between 2009 and 2011, the number and proportion of tests from NHSs increased across all types of test. This finding may reflect increased documentation of NHS referrals or that the laboratory scale-up originally intended to service the HIV-positive population in Tanzania may be associated with a 'spillover effect' amongst the general population.
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Affiliation(s)
- Margaret L McNairy
- ICAP, Columbia University, New York, New York, United States; Weill Cornell Medical College, New York, New York, United States
| | - Charon Gwynn
- ICAP, Columbia University, New York, New York, United States
| | - Miriam Rabkin
- ICAP, Columbia University, New York, New York, United States
| | | | - Yingfeng Wu
- ICAP, Columbia University, New York, New York, United States
| | | | - Travis Lim
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Rubina Imtiaz
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Fausta Mosha
- Ministry of Health and Social Welfare, Dar es Salaam, Republic of Tanzania
| | - Michael Mwasekaga
- Centers for Disease Control and Prevention, Dar es Salaam, Republic of Tanzania
| | | | - Jessica Justman
- ICAP, Columbia University, New York, New York, United States
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Gupta N, Bukhman G. Leveraging the lessons learned from HIV/AIDS for coordinated chronic care delivery in resource-poor settings. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2015; 3:215-20. [PMID: 26699346 DOI: 10.1016/j.hjdsi.2015.09.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 09/22/2015] [Accepted: 09/29/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Neil Gupta
- Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA; Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.
| | - Gene Bukhman
- Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA; Partners in Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda; Program in Global Non-Communicable Diseases and Social Change, Harvard Medical School, Boston, USA
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Oliveira C, Russo G. Vertical interventions and system effects; have we learned anything from past experiences? Pan Afr Med J 2015; 21:262. [PMID: 26523197 PMCID: PMC4607799 DOI: 10.11604/pamj.2015.21.262.6522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 07/21/2015] [Indexed: 11/17/2022] Open
Abstract
The recent Ebola Virus Outbreak had a devastating effect on West Africa's already feeble national health systems. We suggest that such an impact turned out to be catastrophic because it hit particularly hard human resources for health and the delivery of primary healthcare services, which are cross-sectional to any health system. National and international interventions failed to understand the nature of this interaction, and concentrated on attending urgent specific vertical functions to fight the outbreak - the pillars - such as surveillance, logistics, safe burials etc. Such patchwork and vertical intervention strategy was always going to fail to tackle a system-wide problem, particularly in already fragile systems. We suggest that future interventions will have to learn from the experience of past initiatives for the introduction of HIV-AIDS services, which started as vertical programs and ended up including ever growing health system strengthening components.
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Affiliation(s)
- Charlotte Oliveira
- Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Portugal
| | - Giuliano Russo
- Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Portugal ; Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Portugal
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Bertone MP, Witter S. The complex remuneration of human resources for health in low-income settings: policy implications and a research agenda for designing effective financial incentives. HUMAN RESOURCES FOR HEALTH 2015; 13:62. [PMID: 26215040 PMCID: PMC4517656 DOI: 10.1186/s12960-015-0058-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 07/09/2015] [Indexed: 05/21/2023]
Abstract
BACKGROUND Human resources for health represent an essential component of health systems and play a key role to accelerate progress towards universal health coverage. Many countries in sub-Saharan Africa face challenges regarding the availability, distribution and performance of health workers, which could be in part addressed by providing effective financial incentives. METHODS Based on an overview of the existing literature, the paper highlights the gaps in the existing research in low-income countries exploring the different components of health workers' incomes. It then proposes a novel approach to the analysis of financial incentives and delineates a research agenda, which could contribute to shed light on this topic. FINDINGS The article finds that, while there is ample research that investigates separately each of the incomes health workers may earn (for example, salary, fee-for-service payments, informal incomes, "top-ups" and per diems, dual practice and non-health activities), there is a dearth of studies which look at the health workers' "complex remuneration", that is, the whole of the financial incentives available. Little research exists which analyses simultaneously all revenues of health workers, quantifies the overall remuneration and explores its complexity, its multiple components and their features, as well as the possible interaction between income components. However, such a comprehensive approach is essential to fully comprehend health workers' incentives, by investigating the causes (at individual and system level) of the fragmentation in the income structure and the variability in income levels, as well as the consequences of the "complex remuneration" on motivation and performance. This proposition has important policy implications in terms of devising effective incentive packages as it calls for an active consideration of the role that "complex remuneration" plays in determining recruitment, retention and motivation patterns, as well as, more broadly, the performance of health systems. CONCLUSIONS This paper argues that research focusing on the health workers' "complex remuneration" is critical to address some of the most challenging issues affecting human resources for health. An empirical research agenda is proposed to fill the gap in our understanding.
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Affiliation(s)
- Maria Paola Bertone
- ReBUILD consortium, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
- ReBUILD Consortium, IIHD, Queen Margaret University, Edinburgh, UK.
| | - Sophie Witter
- ReBUILD Consortium, IIHD, Queen Margaret University, Edinburgh, UK.
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Verguet S, Kahn JG, Marseille E, Jiwani A, Kern E, Walson JL. Are long-lasting insecticide-treated bednets and water filters cost-effective tools for delaying HIV disease progression in Kenya? Glob Health Action 2015; 8:27695. [PMID: 26065636 PMCID: PMC4463495 DOI: 10.3402/gha.v8.27695] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 05/06/2015] [Accepted: 05/07/2015] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Co-infection with malaria and other infectious diseases has been shown to increase viral load and accelerate HIV disease progression. A recent study in Kenya demonstrated that providing long-lasting insecticide-treated bednets (LLIN) and water filters (WF) to HIV-positive adults with CD4 >350 cells/mm(3) significantly reduced HIV progression. DESIGN We conducted a cost analysis to estimate the potential net financial savings gained by delaying HIV progression and increasing the time to antiretroviral therapy (ART) eligibility through delivering LLIN and WF to 10% of HIV-positive adults with CD4 >350 cells/mm(3) in Kenya. RESULTS Given a 3-year duration of intervention benefit, intervention unit cost of US$32 and patient-year ART cost of US$757 (2011 US$), over the lifetime of ART patients, in Kenya, we estimated the intervention could yield a return on investment (ROI) of 11 (95% uncertainty range [UR]: 5-23), based on a cost of about US$2 million and savings in ART costs of about US$26 million (95% UR: 8-50) (discounted at 3%). Our findings were subjected to a number of sensitivity analyses. Of note, deferral of time to ART eligibility could potentially result in 3,000 new HIV infections not averted by ART and thus decrease ART cost savings to US$14 million, decreasing the ROI to 6. CONCLUSIONS Provision of LLIN and WF could be a cost-saving and practical method to defer time to ART eligibility in the context of highly resource-constrained environments experiencing donor fatigue for HIV/AIDS programs.
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Affiliation(s)
- Stéphane Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA;
| | - James G Kahn
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
- Global Health Sciences, University of California, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | | | - Aliya Jiwani
- Health Strategies International, Arlington, VA, USA
| | - Eli Kern
- Assessment, Policy Development & Evaluation, Public Health-Seattle & King County, WA, USA
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
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